DOI: 10.1148/radiol.2382031851
(Radiology 2006;238:748-751.)
© RSNA, 2006
Case 91: Tuberculous Epididymo-orchitis1
Malai Muttarak, MD and
Wilfred C. G. Peh, MBBS, FRCP, FRCR
1 From the Department of Radiology, Chiang Mai University, Chiang Mai, Thailand (M.M.); and Programme Office, Singapore Health Services, 7 Hospital Drive, #02-09, Singapore 169611 (W.C.G.P.). Received December 3, 2003; revision requested February 12, 2004; revision received March 5; final version accepted March 23.
Address correspondence to W.C.G.P. (e-mail: wilfred{at}pehfamily.per.sg).
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HISTORY
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A 65-year-old man presented with left scrotal pain and swelling of 2 weeks duration. The scrotal swelling was progressively increasing. The patient had no history of testicular trauma or dysuria. There were no other systemic symptoms and no medical history of note. At physical examination, a slightly tender mass was palpable within the left hemiscrotum. The left testis itself was not felt distinctly. Findings in the right testis were normal. The overlying scrotal skin showed no sign of inflammation. The patient was treated with a course of broad-spectrum antibiotics, without improvement. Ultrasonography (US) was then performed.
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IMAGING FINDINGS
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Transverse US images show a normal right testis and an enlarged left testis with multiple small hypoechoic nodules that is surrounded by a hydrocele (Fig 1). Longitudinal US images of the left hemiscrotum show multiple small hypoechoic nodules that are diffusely scattered throughout the left testis in a miliary pattern. There is also nodular, inhomogeneously hypoechoic enlargement of the head and tail of the epididymis. Mild scrotal skin thickening is also present (Fig 2).
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Figure 1: Transverse US images of the right (R) and left (L) testes show a normal right testis and an enlarged heterogeneously echoic left testis (thin arrows). Multiple hypoechoic nodules are seen in the left testis. There is a surrounding hydrocele (*). Part of the enlarged epididymitis (thick arrow) is seen. Mild left skin thickening is present (arrowheads) in the left testis compared with the skin of the right testis.
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Figure 2: Longitudinal composite US images of the left hemiscrotum show multiple small hypoechoic nodules within the diffusely enlarged testis. The left side of this figure shows the upper hemiscrotum, and the right side shows the lower hemiscrotum. There is also nodular inhomogeneously hypoechoic enlargement of the head (H) and tail (T) of the epididymis. A small speck of calcification (arrow) is seen in the tail of the epididymis.
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DISCUSSION
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In a patient presenting with scrotal swelling, the US detection of epididymal abormalities, skin thickening, and hydrocele, in addition to a heterogeneously enlarged testis, suggests that this swelling is caused by an infection rather than a testicular tumor. The presence of miliary nodularity of the testis should alert the radiologist to the possible diagnosis of tuberculous epididymo-orchitis. Lack of response to conventional antibiotics further supports this diagnosis (1). The diagnosis of tuberculous epididymo-orchitis was confirmed with subsequent resolution of the lesions (Fig 3) after administration of antituberculous drugs (ie, isoniazid, rifampicin, parazinamide, ethambutol) for 2 months, followed by administration of isoniazid and rifampicin for an additional 4 months. The patient had no other site of tuberculosis, and findings of chest radiography were normal. This patient was not immunocompromised, and he did not have the human immunodeficiency virus.
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Figure 3: Follow-up images obtained after 7 months of antituberculous treatment show complete recovery. The appearance of longitudinal US images of the right (R) and left (L) testes is normal.
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Tuberculous infection of the scrotum is rare and occurs in approximately 7% of patients with tuberculosis (2). Tuberculosis has become a common opportunistic infection because of the human immunodeficiency virus pandemic (3). The incidence of extrapulmonary tuberculosis has correspondingly increased, with the genitourinary system being the most commonly affected site. In male patients, epididymitis is the most common symptom of genitourinary tuberculosis (4). Whether this type of infection results from hematogeneous dissemination or from direct spread from the prostate and seminal vesicles remains a point of contention (2,5). Prevalence of an associated history of previous tuberculous infection ranges from 0% to 70% of cases (4).
At the initial stage of infection, the epididymis alone is usually involved. Infection then spreads to the ipsilateral testis, particularly if appropriate antituberculous treatment is not administered promptly. The occurrence of isolated testicular tuberculous is rare (6). Pathologically, the earliest lesions are seen as discrete or conglomerate yellowish necrotic areas in the tail of the epididymis. This inflammatory process then involves the rest of the epididymis or heals, often with calcifications. Tuberculous orchitis is considered a later stage of the disease process that extends from the epididymis.
Clinically, scrotal tuberculosis often cannot be distinguished from lesions such as testicular tumor and infarction and may even mimic testicular torsion. Men aged 20–50 years are affected most commonly (4,7). Patients may present with painful or painless enlargement of the scrotum. US is currently the best technique for imaging the scrotum and its contents, and it can be used to reliably differentiate between extra- and intratesticular lesions. Addition of color Doppler US enhances diagnostic accuracy (8).
The following US patterns of tuberculous epididymitis have been described: (a) diffusely enlarged heterogeneously hypoechoic tuberculous epididymitis, (b) diffusely enlarged homogeneously hypoechoic tuberculous epididymitis, and (c) nodular-enlarged heterogeneously hypoechoic tuberculous epididymitis (1,2,5,9). The latter pattern was observed in our patient. Calcifications may be present, and they may be a useful differentiating feature. The heterogeneous appearance of the epididymis is thought to be caused by the various stages of the disease process, such as caseation necrosis, granuloma formation, and fibrosis (5,9).
US patterns of tuberculous orchitis are as follows: (a) diffusely enlarged heterogeneously hypoechoic testis, (b) diffusely enlarged homogeneously hypoechoic testis, (c) nodular enlarged heterogeneously hypoechoic testis, and (d) presence of multiple small hypoechoic nodules in an enlarged testis (1,2,5,9). The latter pattern, also known as the miliary pattern, was observed in this patient. This miliary US appearance has been suggested to be characteristic of tuberculous orchitis (2), and it has been observed by others (1,9). Other US features of scrotal tuberculosis include scrotal skin thickening, scrotal abscesses, and scrotal sinus tract (1).
The major clinical differential diagnoses of tuberculous epididymo-orchitis are testicular tumor, testicular torsion, bacterial epididymo-orchitis, and sarcoid. At US, testicular tumors usually appear as discrete masses, or the entire testis may be involved and diffusely or heterogeneously hypoechoic. Seminomas and lymphomas tend to be homogeneous, while nonmseminomatous tumors tend to be heterogeneous (10). The presence of epididymal enlargement in conjunction with a testicular lesion is suggestive of an infection rather than a neoplastic cause.
The US appearances of testicular torsion are variable, and they depend on the duration of torsion. In the acute phase, the testis is enlarged and diffusely hypoechoic. Later, the testis may appear heterogeneous; this is due to hemorrhage and necrosis. Reactive hydrocele and skin thickening may also occur. In such circumstances, color Doppler US is useful, as blood flow within subjects with testicular torsion is reduced or absent, whereas it is increased in subjects with an inflamed testis (8,11). Generally, with careful interpretation of US images, differentiation of testicular tumor and testicular torsion caused by infection is not difficult.
Differentiation of bacterial epididymo-orchitis from tuberculous epididymo-orchitis may be problematic if there is insufficient clinical information. In cases of bacterial infection, patients typically present with fever, dysuria, and severe and acute scrotal pain. On palpation, the affected scrotum is usually hot, swollen, and tender. These patients usually respond well to conventional antibiotics. Although both bacterial and tuberculous infections may involve both the epididymis and the testes, according to Kim et al (5) and Chung et al (9), finding a heterogeneously hypoechoic pattern of epididymal enlargement favors a diagnosis of tuberculosis. Color Doppler US may be useful, as a diffuse increased blood flow pattern is seen in subjects with bacterial epididymitis, whereas focal linear or spotty blood flow signals are seen in the peripheral zone of the affected epididymis in subjects with tuberculosis (12). In patients with an epididymal abscess, color Doppler flow imaging demonstrates a lower degree of blood flow in the peripheral portion of a large abscess, which is suggestive of tuberculous infection (13).
Patients with tuberculous epididymitis or epididymo-orchitis usually respond to antituberculous therapy. However, surgery may be required in severe cases. In summary, the diagnosis of tuberculous epididymo-orchitis should be considered in patients who present with scrotal swelling if US images show both epididymal and testicular lesions. Additional useful information for differentiation includes intrascrotal calcifications and sinus tract, clinical evidence of tuberculosis elsewhere in the body, immunocompromise, and failure to respond to conventional antibiotics.
Congratulations to the 86 individuals and one resident group who submitted the most likely diagnosis (tuberculous epididymo-orchitis) for Diagnosis Please, Case 91. Credit was given only if tuberculosis was specifically mentioned. The names and locations of the individuals and resident groups, as submitted, are as follows:
Individual Responses
- Hisashi Abe, Osaka, Japan
- Gholamali Afshang, MD, Tinley Park, Ill
- Oguz Akin, MD, New York, NY
- Canan Altay, MD, Izmir, Turkey
- Albert J. Alter, Madison, Wis
- Bruce Arose, MD, Hartford, Conn
- Patricia A. Athey, MD, Houston, Tex
- Idun Augland, Bergen, Norway
- Aaron Scott Bailey, MD, McKinney, Tex
- Ken Baliga, Rockford, Ill
- Eric L. Bressler, MD, Minnetonka, Minn
- Ghislain Brousseau, MD, Charlesbourg, Quebec, Canada
- Michael P. Buetow, MD, Okemos, Mich
- Stephen Buetow, MD, Evans, Ga
- Luisa F. Cervantes, Miami, Fla
- Bharath Chinta, Rochester Hills, Mich
- Y. S. Cordoliani, MD, Paris, France
- Peter Corr, Al Ain, United Arab Emirates
- Peter C. De Baets, MD, Damme, Belgium
- Mustafa Kemal Demir, MD, Istanbul, Turkey
- Thaworn Dendumrongsup, MD, Songkla, Thailand
- Susana Dias, Porto, Portugal
- Mark Thomas DiMarcangelo, DO, MS, FACR, Cherry Hill, NJ
- Lincoln Olivio Diniz, MD, MPH, Chicago, Ill
- Jordi Catala Forteza, Barcelona, Spain
- Akira Fujikawa, Tokyo, Japan
- Pedro Garcia, Gijon, Spain
- Douglas Gardner, MD, Windsor, Ontario, Canada
- Mark Goldshein, MD, Andover, Mass
- Dr Francisco J. Gonzalez, Cantabria, Spain
- Ferris M. Hall, MD, Boston, Mass
- Yukihiro Hama, MD, PhD, Bethesda, Md
- Ian Hammond, MD, Ottawa, Ontario, Canada
- Ronald J. Homer, MD, Weston, Conn
- S. Pinar Karakas, New Hyde Park, NY
- P. Kiely, MB, Limerick, Ireland
- Osamu Kizu, Shiga, Japan
- Madhu Kumar, Davangere, India
- Yu-Ting Kuo, MD, Kaohsiung, Taiwan
- Alexis Lacout, MD, Paris, France
- Mario Laguna, West Allis, Wis
- John T. Lim, MD, Newport Coast, Calif
- Bart Maes, MD, Tongeren, Belgium
- N. B. S. Mani, MD, Nassau, Bahamas
- Frank McKowne, MD, Vancouver, Wash
- Ziad F. Meer, FRCR, London, United Kingdom
- Jonathan Meyer, MD, Chicago, Ill
- Manabu Minami, MD, Ibaraki, Japan
- Sankar Ranjan Mondal, MD, Nassau, Bahamas
- Gregg E. Moral, MD, Cedarburg, Wis
- Tammam Nehme, East Wenatchee, Wash
- Karl F. R. Neufang, MD, Euskirchen, Germany
- Tuan Duc Nguyen, MD, Voss, Norway
- Mizuki Nishino, MD, Boston, Mass
- Michael T. O'Loughlin, MD, West Hartford, Conn
- Narendrakumar P. Patel, MD, Newburgh, NY
- Christopher Payne, MD, Greensboro, NC
- Shawn P. Quillin, MD, Charlotte, NC
- Ryan Rebello, MD, Hamilton, Ontario, Canada
- Mathieu Rodallec, Paris, France
- Sorracha Rookkapan, MD, Songkla, Thailand
- Hatice Tuba Sanal, MD, Ankara, Turkey
- Steven M. Schultz, MD, Fort Worth, Tex
- Niall Sheehy, MD, Dublin, Ireland
- Taro Shimono, MD, Osaka, Japan
- Darrin S. Smith, MD, Visalia, Calif
- James D. Sprinkle, Jr, MD, Spotsylvania, Va
- Scott D. Steenburg, MD, Mount Pleasant, SC
- Marius Stellmann, MD, Stade, Germany
- Simon Strauss, MB ChB, Kfar Shmaryahu, Israel
- Kouichi Sugiyama, Hamamatsu, Japan
- Vinod Sukumaran, Davangere, India
- Eliko Tanaka, Yokohama, Japan
- Toyohiko Tanaka, Shiga, Japan
- Douglas L. Teich, MD, Brookline, Mass
- Eugene Tong, MD, Austin, Tex
- William C. Torreggiani, Dublin, Ireland
- Hiroyuki Ueda, Kyoto, Japan
- Piet Vanhoenacker, MD, Moorsel, Belgium
- Joan C. (Kai) Vilanova, MD, Girona, Spain
- Christopher Vittore, MD, Rockford, Ill
- Nicolaus A. Wagner-Bartak, MD, Houston, Tex
- Jeff West, MD, Jacksonville, Fla
- Stanko Yovichevich, MD, Sydney, Australia
- Joe Yut, Olathe, Kan
- Yu Zhang, San Francisco, Calif
Resident group responses
- Hospital of the University of Pennsylvania Radiology Residents, Philadelphia, Pa
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FOOTNOTES
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| Part one of this case appeared 4 months previously and may contain larger images.
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References
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- Drudi FM, Laghi A, Iannicelli E, et al. Tubercular epididymitis and orchitis: US patterns. Eur Radiol 1997;7:1076–1078.[CrossRef][Medline]
- Raviglione MC, Snider DE Jr, Kochi A. Global epidemiology of tuberculosis: morbidity and mortality of a worldwide epidemic. JAMA 1995;273:220–226.[Abstract/Free Full Text]
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- Chung JJ, Kim MJ, Lee T, Yoo HS, Lee JT. Sonographic findings in tuberculous epididymitis and epididymo-orchitis. J Clin Ultrasound 1997;25:390–394.[CrossRef][Medline]
- Nachtsheim DA, Scheible FW, Gosink B. Ultrasonography of testis tumors. J Urol 1983;129:978–981.[Medline]
- Martin B, Conte J. Ultrasonography of the acute scrotum. J Clin Ultrasound 1987;15:37–44.[Medline]
- Yang DM, Chang MS, Oh YH, Yoon MH, Kim HS, Chung JW. Chronic tuberculous epididymitis: color Doppler US findings with histopathologic correlation. Abdom Imaging 2000;25:559–562.[CrossRef][Medline]
- Yang DM, Yoon MH, Kim HS, et al. Comparison of tuberculous and pyogenic epididymal abscesses: clinical, gray-scale sonographic, and color Doppler sonographic features. AJR Am J Roentgenol 2001;177:1131–1135.[Abstract/Free Full Text]
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TOP
HISTORY
IMAGING FINDINGS
