“Granulomatous Epididymitis” possibly due to TB

By

Bijan Sadrifrom Tehran University of Medical Sciences

Dr. Gillian LiebermanHarvard Medical School

November 2001

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Our Patient 44 Years Old Male

with the Chief Complain of

Drainage from the right scrotum

Courtesy of Dr. Robert Kane

BIDMC east campus US unit

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• Drainage of whitish fluid from right scrotum over the last ten days

• Sensation of Pain and pressure• A similar episode one year

before spontaneously resolved

Present Illness:

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Past Medical History:• Bilateral inguinal hernia repair

during childhood• Left orchiectomy.(Complication

of hernial repair) • Mesh in the right inguinal canal

for his hernia

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Examination:

• Sinus tract at the lower portion of scrotum that tracks to the lower portion of testicle

• Testicle itself not involved

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Social History:

• The patient claims that ejaculation relieves the sensation of pressure and pain

• May have high risk behavior

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Plan:

•Testicular U/S• Resection of the scrotal

sinus tract

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Anatomy: Normal Testis

Head

BodyTail

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Anatomy: Normal Testis

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Our Patient: Testicular Ultrasound

• The right testis: normal in size, echogenicity and vascular flow.

Courtesy of Dr. Robert Kane

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Our Patient: Testicular Ultrasound

• The right testis: normal in size, echogenicity and vascular flow.

Courtesy of Dr. Robert Kane

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Our Patient: Testicular Ultrasound

• The right testis: normal in size, echogenicity and vascular flow.

Courtesy of Dr. Robert Kane

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Our Patient: Epididymal Ultrasound

• The right epididymis: abnormal in thickness and echogenicity

Courtesy of Dr. Robert Kane

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Our Patient: Epididymal Ultrasound

• The right epididymis: abnormal in thickness and echogenicity

Courtesy of Dr. Robert Kane

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Our Patient: Epididymal Ultrasound• The head and

body of the epididymis: hypoechoic, relatively homogeneous appearance suggesting microtubular dilatation.

Courtesy of Dr. Robert Kane

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Our Patient: Epididymal Ultrasound

• The tail of the epididymis: markedly enlarged, heterogeneous and hypervascular,

• Size 1.6 x 2.9 cm.

Courtesy of Dr. Robert Kane

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Our Patient: Epididymal Ultrasound

• The tail of the epididymis: markedly enlarged, heterogeneous and hypervascular,

• Size 1.6 x 2.9 cm.

Courtesy of Dr. Robert Kane

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Our Patient: Epididymal Ultrasound

• The tail of the epididymis: markedly enlarged, heterogeneous and hypervascular,

• Size 1.6 x 2.9 cm.

Courtesy of Dr. Robert Kane

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Our Patient: Scrotal Ultrasound

• Multiseptated loculated hydrocele along the medial hemiscrotum contiguous to the enlarged epididymis.

Courtesy of Dr. Robert Kane

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Our Patient: Scrotal Ultrasound

• Multiseptated loculated hydrocele along the medial hemiscrotum contiguous to the enlarged epididymis.

Courtesy of Dr. Robert Kane

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Our Patient: Scrotal Ultrasound

• Scans over the sinus tract: opening in the scrotal skin along the caudal aspect of the scrotal sac.

Courtesy of Dr. Robert Kane

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Our Patient: Scrotal Ultrasound

• Fistulous tract can be followed directly into the enlarged and abnormal epididymal tail.

Courtesy of Dr. Robert Kane

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Our Patient: Scrotal Ultrasound

• Fistulous tract can be followed directly into the enlarged and abnormal epididymal tail.

Courtesy of Dr. Robert Kane

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Diagram of abnormalities:

Head

BodyTail mass

Hydrocele

Dialated Head and Body

Fistula

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Conclusion:

• Dilation of the epididymal head and body

• Enlargement of the epididymal tail

• Complex septated hydrocele• Fistula connected to the tail

Courtesy of Dr. Robert Kane

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Discussion:Epididymal dilation

Due to?

Hernia repairs surgery

Epididymal tail mass

Obstruction

Courtesy of Dr. Robert Kane

Why?Obstruction

Environment for bacteria to grow

Inflammation

epididymitisCourtesy of Dr. Robert Kane 27

Enlarged Tail:

Granulomatous Disease

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The Disease Is Chronic

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Loculated hydrocele

Old Abscess

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The pathogen caused erosion and fistula to the

skin

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Differential Diagnosis:• Granulomatous epididymitis*

* Granulomatous epididymo-orchitis: sonographic features and clinical outcome in brucellosis, tuberculosis and idiopathic granulomatous epididymo-orchitis. J Urol. 1998 Jun;159(6):1954-7 Salmeron I, et all

1. Brucellosis

2. Tuberculosis3. Idiopathic granulomatous

epididymo-orchitis• Epididymal tumors (very uncommon)

• Other bacterial infections(?)

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Plan:

• Resection of the Sinus Track of the Scrotum

• Antibiotics

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Tuberculous Epididymitis As Secondary Tuberculosis in USA

•Prevalent Among AIDS Patients•Reported As the First Manifestation of AIDS*

* Kumar P, Shashikala P, Chandrashekar HR, Alva NK.

Acquired immunodeficiency syndrome presenting as testicular tuberculosis.

J Assoc Physicians India. 2000 Nov;48(11):1111-2.34

Tuberculous Epididymitis Is * Secondary to Lung Infection and

From There Either•Infection Descending From Kidney or•Hematogenous

* Chung JJ, Kim MJ, Lee T, Yoo HS, Lee JT.

Sonographic findings in tuberculous epididymitis and epididymo-orchitis.

J Clin Ultrasound. 1997 Sep;25(7):390-4. 35

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Sonographic Findings of Tuberculous Epididymitis :*

• Heterogenous, hypoechoic swelling of epididymis

• Hypoechoic lesion of the testis• Associated sinus tract• Extratesticular calcifications

* Chung JJ, Kim MJ, Lee T, Yoo HS, Lee JT.

Sonographic findings in tuberculous epididymitis and epididymo-orchitis.

J Clin Ultrasound. 1997 Sep;25(7):390-4.

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Acknowledgements:

Robert Kane, MDGillian Lieberman, MDMs. Pamela Lepkowski

Larry Barbaras and Cara Lyn d’amour