Brucellar epididymo-orchitis in Saudi Arabia: a retrospective study of 26 cases and review of the literature.

OBJECTIVE: To review the clinical and laboratory features and response to treatment of patients with acute brucellar epididymo-orchitis reporting to a tertiary care hospital in Riyadh, and to compare these with other cases reported previously. PATIENTS AND METHODS: In this retrospective study, records of all 26 adult patients with brucellosis, who presented with epididymitis or epididymo-orchitis at a tertiary hospital in Riyadh from 1983 to 2000, were reviewed. Positive blood culture or high agglutination titres of > or = 1 : 320 and positive clinical manifestations of brucellosis were the main criteria for diagnosing brucellosis. Among these cases, epididymitis or epididymo-orchitis was diagnosed on the basis of a typical history of gradual onset of scrotal pain and findings of enlarged tender testes and/or epididymis.
RESULTS: Epididymo-orchitis occurred in 1.6% of all patients with brucellosis. Most (58%) were 25--44 years old; approximately 77% of the patients presented with acute symptoms of < 2 weeks' duration. All patients complained of swollen painful testicles. Other presenting symptoms included undulant fever (96%), chills (54%) and arthralgia (23%). Four patients had dysuria and one haematuria. Ten patients gave a positive history of ingestion of raw milk and milk products; one patient had laboratory-acquired brucellosis. Six patients had unilateral epididymo-orchitis (two with features of florid presentation); the remaining 20 had only orchitis (bilateral in two, right in 10 and left in eight). Leucocytosis was present in six patients; 25 had initial agglutination titres of > 1 : 320 and the remaining patient had a positive blood culture. All patients received combined therapy with streptomycin for the first 2 weeks (or oral rifampicin for 6 weeks) with doxycycline or tetracycline for 6 weeks. All showed improvement, fever subsided in 2--5 days and the scrotal enlargement and tenderness regressed. Only one patient had a relapse within one year.
CONCLUSION: In brucellosis-endemic areas, clinicians encountering epididymo-orchitis should consider the likelihood of brucellosis. A careful history, a meticulous physical examination and a rapid laboratory evaluation help in diagnosis. Clinical and serological data are sufficient for diagnosis. Leucocytosis is not an atypical feature of brucellar epididymo-orchitis and so cannot be used for differentiating it from the nonspecific variety. Conservative management with combination antibiotic therapy is adequate for managing brucellar epididymo-orchitis.