SRU RESIDENT TEACHING CASE
Tuberculous Epididymitis Kevin Otey Herman, MD and Ellie Rose Lee, MD
CLINICAL HISTORY A 68-year-old man with a history of urothelial carcinoma of the bladder, status post multiple transurethral resections and subsequent treatment with intravesical instillation of bacillus Calmette-Guerin (BCG), presented with right testicular pain and edema. He underwent antibiotic therapy with 2 complete courses of ciprofloxacin and doxycycline. Scrotal ultrasound was performed when the patient’s symptoms failed to respond to treatment. The patient was diagnosed with tuberculous epididymitis and began treatment with rifampin, isoniazid, and pyridoxine. His symptoms improved initially but recurred despite a repeated course of antituberculous treatment. His ultrasound findings continued to progress and the patient ultimately underwent orchiectomy.
DIAGNOSIS Tuberculous epididymitis was diagnosed, which was confirmed through pathologic analysis after orchiectomy.
IMAGE FINDINGS Scrotal ultrasound at presentation showed a heterogeneously hypoechoic, enlarged right epididymis and hydrocele (Fig. 1). Ultrasound performed after the initial course of antituberculous triple therapy showed further enlargement of the epididymis with a nodular heterogeneous appearance and development of a fluid collection in the epididymal tail (Figs. 2, 3). Further follow-up ultrasound examination after a repeated course of antituberculous treatment showed an increasingly hypoechoic appearance of the epididymis with development of a debris-containing hydrocele (Fig. 4).
FIGURE 1. Initial ultrasound of tuberculous epididymitis. A, Longitudinal gray-scale image of the right hemiscrotum shows heterogeneously hypoechoic enlargement of the epididymis (E). The testicle (T) appears normal. B, Color Doppler image of the right hemiscrotum shows increased blood flow in right epididymis (E) and a hydrocele (*). T, right testicle. Figure 1 can be viewed in color online at www.ultrasound-quarterly.com.
of the genitourinary system. In a study performed by Lamm et al, epididymo-orchitis occurred in 0.4% of 2602 patients. Epididymitis is thought to occur secondary to BCG-contaminated urine
DISCUSSION Bacillus Calmette-Guerin is a live attenuated strain of the bovine tuberculosis bacillus, Mycobacterium bovis. Intravesical BCG therapy is used as an adjuvant treatment for urothelial bladder cancers and has been shown to decrease recurrence compared with surgery alone.1 Instillation of the mycobacteria into the bladder causes an inflammatory response leading to destruction of tumor cells. Complications related to intravesical instillation of BGC are rare, including granulomatous infections Received for publication September 17, 2014; accepted December 4, 2014. University of North Carolina, Chapel Hill, NC. The authors declare no conflict of interest. Reprints: Kevin Otey Herman, MD, Radiology, University of North Carolina, Manning Dr, Chapel Hill, NC 27514 (e-mail: [email protected]). Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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www.ultrasound-quarterly.com
FIGURE 2. Follow-up 1 month after the initial course of treated tuberculous epididymitis. A, Longitudinal gray-scale image of the right hemiscrotum shows that the epididymis (E) is diffusely enlarged with a nodular heterogeneous hypoechoic pattern (arrows). B, Longitudinal gray-scale image of the right hemiscrotum shows enlarged epididymis (E) with fluid collection (arrow) in the epididymal tail. There is a small hydrocele (*). The testicle (T) appears normal. Figure 2 can be viewed in color online at www.ultrasound-quarterly.com. Ultrasound Quarterly
& Volume 31, Number 3, September 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Ultrasound Quarterly
& Volume 31, Number 3, September 2015
Tuberculous Epididymitis
epididymitis. However, both types will show an overall decrease in blood flow in cases of chronic infection. The differential diagnosis for epididymal enlargement also includes benign epididymal masses such as adenomatoid tumors. Hyperechoic rims may be seen in both tuberculous epididymitis and adenomatoid tumors, representing abscess wall in the former and compressed epididymal tissue in the latter. Benign epididymal masses tend to display a more homogeneous appearance than the characteristic heterogeneously hypoechoic appearance of tuberculous epididymitis.6 Clinical history is also useful in differentiating granulomatous from bacterial epididymitis. Patients with bacterial infection tend to present with fever, dysuria, and acute pain. However, patients with tuberculous epididymitis tend to
FIGURE 3. Follow-up 2 months after the initial course of treated tuberculous epididymitis. A, Longitudinal gray-scale image of the right hemiscrotum shows progressive nodular enlargement of the epididymis with heterogeneous echotexture (E). There is a large hydrocele (*) surrounding the normal-appearing right testicle (T). B, Color Doppler of the right hemiscrotum shows decreased blood flow. Hydrocele (*) is noted. T, normal right testicle. C, Longitudinal gray-scale images showing side-by-side comparison of the right and left hemiscrotums. The right epididymis (RE) is enlarged and heterogeneously hypoechoic compared with the normal-appearing left epididymis (LE). The right and left testes (RT and LT) are normal in appearance. There is a large right hydrocele (*). Figure 3B can be viewed in color online at www.ultrasound-quarterly.com.
refluxing from the bladder and extending through the prostate and seminal vesicles.2 Gray-scale sonography of BCG-related epididymitis can exhibit 3 different patterns: heterogeneously hypoechoic diffuse enlargement; homogeneously hypoechoic diffuse enlargement; and heterogeneously hypoechoic, nodular pattern of enlargement.2 The heterogeneously hypoechoic echotexture has been suggested as more specific to granulomatous infection, which is likely caused by the staged process that includes caseation necrosis, granuloma formation, and fibrosis.3,4 Bacterial epididymitis often presents with diffuse enlargement of the epididymis and a homogeneously hypoechoic echotexture. The heterogeneously hypoechoic pattern of epididymal enlargement has been shown to reliably differentiate tuberculous from nonYtuberculous epididymitis in multiple series.3,5 Bacterial epididymitis often shows a greater degree of hyperemia in its early stages than that seen in tuberculous
FIGURE 4. Follow-up 6-month ultrasound examination after a repeated course of antituberculous therapy for the tuberculous epididymitis. A, Longitudinal color Doppler image of the right hemiscrotum shows that echogenicity of the epididymis (E) has become more hypoechoic with decreased epididymal blood flow. *, hydrocele; T, right testicle. B, Longitudinal gray-scale image of the right hemiscrotum shows a predominantly hypoechoic, heterogeneous appearance of the right epididymis (E). Debris (arrows) is seen within the hydrocele (*). Figure 4A can be viewed in color online at www.ultrasound-quarterly.com.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ultrasound-quarterly.com
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Ultrasound Quarterly
Herman and Lee
have lesser tenderness than in bacterial epididymitis, leading patients to present with a larger, indurated mass.6 Perhaps more than any other factor, a history of bladder cancer with BCG therapy should raise suspicion for a granulomatous process. Granulomatous epididymitis is typically responsive to antituberculous therapy with rifampin, isoniazid, and pyridoxine. Ultrasound is the modality of choice to follow treatment responsiveness. Orchiectomy is performed in cases of testicular abscess or recalcitrant cases in which symptoms of testicular pain and swelling do not resolve after antibiotic therapy. Granulomatous epididymitis must be considered in patients with a history of intravesical BCG therapy who present with scrotal pain because its detection can guide treatment early on.
204
www.ultrasound-quarterly.com
& Volume 31, Number 3, September 2015 REFERENCES
1. Oosterlinck W, Lobel B, Jakse G, et al. Guidelines on bladder cancer. Eur Urol. 2002;41:105. 2. Salvador R, Vilana R, Bargalio X, et al. Tuberculous epididymo-orchitis after intravesical BCG therapy for superficial bladder carcinoma. J Ultrasound Med. 2007;26:671Y674. 3. Chung J, Kim M, Lee T, et al. Sonographic findings in tuberculous epididymitis and epididymo-orchitis. J Clin Ultrasound;25:390Y394. 4. Demers V, Pelsser V. BCGitis: a rare case of tuberculous epididymo-orchitis following intravesical bacillus Calmette-Guerin therapy. J Radiol Case Rep. 2012;6:16Y21. 5. Kim SH, Pollack HM, Cho KS, et al. Tuberculous epididymitis and epididymo-orchitis: sonographic findings. J Urol. 1993;150:81Y84. 6. Yang D, Kim SH, Kim HN, et al. Differential diagnosis of focal epididymal lesions with gray scale sonographic, color Doppler sonographic, and clinical features. J Ultrasound Med. 2003;22:135Y142.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Tuberculous Epididymitis Kevin Otey Herman, MD and Ellie Rose Lee, MD
CLINICAL HISTORY A 68-year-old man with a history of urothelial carcinoma of the bladder, status post multiple transurethral resections and subsequent treatment with intravesical instillation of bacillus Calmette-Guerin (BCG), presented with right testicular pain and edema. He underwent antibiotic therapy with 2 complete courses of ciprofloxacin and doxycycline. Scrotal ultrasound was performed when the patient’s symptoms failed to respond to treatment. The patient was diagnosed with tuberculous epididymitis and began treatment with rifampin, isoniazid, and pyridoxine. His symptoms improved initially but recurred despite a repeated course of antituberculous treatment. His ultrasound findings continued to progress and the patient ultimately underwent orchiectomy.
DIAGNOSIS Tuberculous epididymitis was diagnosed, which was confirmed through pathologic analysis after orchiectomy.
IMAGE FINDINGS Scrotal ultrasound at presentation showed a heterogeneously hypoechoic, enlarged right epididymis and hydrocele (Fig. 1). Ultrasound performed after the initial course of antituberculous triple therapy showed further enlargement of the epididymis with a nodular heterogeneous appearance and development of a fluid collection in the epididymal tail (Figs. 2, 3). Further follow-up ultrasound examination after a repeated course of antituberculous treatment showed an increasingly hypoechoic appearance of the epididymis with development of a debris-containing hydrocele (Fig. 4).
FIGURE 1. Initial ultrasound of tuberculous epididymitis. A, Longitudinal gray-scale image of the right hemiscrotum shows heterogeneously hypoechoic enlargement of the epididymis (E). The testicle (T) appears normal. B, Color Doppler image of the right hemiscrotum shows increased blood flow in right epididymis (E) and a hydrocele (*). T, right testicle. Figure 1 can be viewed in color online at www.ultrasound-quarterly.com.
of the genitourinary system. In a study performed by Lamm et al, epididymo-orchitis occurred in 0.4% of 2602 patients. Epididymitis is thought to occur secondary to BCG-contaminated urine
DISCUSSION Bacillus Calmette-Guerin is a live attenuated strain of the bovine tuberculosis bacillus, Mycobacterium bovis. Intravesical BCG therapy is used as an adjuvant treatment for urothelial bladder cancers and has been shown to decrease recurrence compared with surgery alone.1 Instillation of the mycobacteria into the bladder causes an inflammatory response leading to destruction of tumor cells. Complications related to intravesical instillation of BGC are rare, including granulomatous infections Received for publication September 17, 2014; accepted December 4, 2014. University of North Carolina, Chapel Hill, NC. The authors declare no conflict of interest. Reprints: Kevin Otey Herman, MD, Radiology, University of North Carolina, Manning Dr, Chapel Hill, NC 27514 (e-mail: [email protected]). Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
202
www.ultrasound-quarterly.com
FIGURE 2. Follow-up 1 month after the initial course of treated tuberculous epididymitis. A, Longitudinal gray-scale image of the right hemiscrotum shows that the epididymis (E) is diffusely enlarged with a nodular heterogeneous hypoechoic pattern (arrows). B, Longitudinal gray-scale image of the right hemiscrotum shows enlarged epididymis (E) with fluid collection (arrow) in the epididymal tail. There is a small hydrocele (*). The testicle (T) appears normal. Figure 2 can be viewed in color online at www.ultrasound-quarterly.com. Ultrasound Quarterly
& Volume 31, Number 3, September 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Ultrasound Quarterly
& Volume 31, Number 3, September 2015
Tuberculous Epididymitis
epididymitis. However, both types will show an overall decrease in blood flow in cases of chronic infection. The differential diagnosis for epididymal enlargement also includes benign epididymal masses such as adenomatoid tumors. Hyperechoic rims may be seen in both tuberculous epididymitis and adenomatoid tumors, representing abscess wall in the former and compressed epididymal tissue in the latter. Benign epididymal masses tend to display a more homogeneous appearance than the characteristic heterogeneously hypoechoic appearance of tuberculous epididymitis.6 Clinical history is also useful in differentiating granulomatous from bacterial epididymitis. Patients with bacterial infection tend to present with fever, dysuria, and acute pain. However, patients with tuberculous epididymitis tend to
FIGURE 3. Follow-up 2 months after the initial course of treated tuberculous epididymitis. A, Longitudinal gray-scale image of the right hemiscrotum shows progressive nodular enlargement of the epididymis with heterogeneous echotexture (E). There is a large hydrocele (*) surrounding the normal-appearing right testicle (T). B, Color Doppler of the right hemiscrotum shows decreased blood flow. Hydrocele (*) is noted. T, normal right testicle. C, Longitudinal gray-scale images showing side-by-side comparison of the right and left hemiscrotums. The right epididymis (RE) is enlarged and heterogeneously hypoechoic compared with the normal-appearing left epididymis (LE). The right and left testes (RT and LT) are normal in appearance. There is a large right hydrocele (*). Figure 3B can be viewed in color online at www.ultrasound-quarterly.com.
refluxing from the bladder and extending through the prostate and seminal vesicles.2 Gray-scale sonography of BCG-related epididymitis can exhibit 3 different patterns: heterogeneously hypoechoic diffuse enlargement; homogeneously hypoechoic diffuse enlargement; and heterogeneously hypoechoic, nodular pattern of enlargement.2 The heterogeneously hypoechoic echotexture has been suggested as more specific to granulomatous infection, which is likely caused by the staged process that includes caseation necrosis, granuloma formation, and fibrosis.3,4 Bacterial epididymitis often presents with diffuse enlargement of the epididymis and a homogeneously hypoechoic echotexture. The heterogeneously hypoechoic pattern of epididymal enlargement has been shown to reliably differentiate tuberculous from nonYtuberculous epididymitis in multiple series.3,5 Bacterial epididymitis often shows a greater degree of hyperemia in its early stages than that seen in tuberculous
FIGURE 4. Follow-up 6-month ultrasound examination after a repeated course of antituberculous therapy for the tuberculous epididymitis. A, Longitudinal color Doppler image of the right hemiscrotum shows that echogenicity of the epididymis (E) has become more hypoechoic with decreased epididymal blood flow. *, hydrocele; T, right testicle. B, Longitudinal gray-scale image of the right hemiscrotum shows a predominantly hypoechoic, heterogeneous appearance of the right epididymis (E). Debris (arrows) is seen within the hydrocele (*). Figure 4A can be viewed in color online at www.ultrasound-quarterly.com.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ultrasound-quarterly.com
203
Ultrasound Quarterly
Herman and Lee
have lesser tenderness than in bacterial epididymitis, leading patients to present with a larger, indurated mass.6 Perhaps more than any other factor, a history of bladder cancer with BCG therapy should raise suspicion for a granulomatous process. Granulomatous epididymitis is typically responsive to antituberculous therapy with rifampin, isoniazid, and pyridoxine. Ultrasound is the modality of choice to follow treatment responsiveness. Orchiectomy is performed in cases of testicular abscess or recalcitrant cases in which symptoms of testicular pain and swelling do not resolve after antibiotic therapy. Granulomatous epididymitis must be considered in patients with a history of intravesical BCG therapy who present with scrotal pain because its detection can guide treatment early on.
204
www.ultrasound-quarterly.com
& Volume 31, Number 3, September 2015 REFERENCES
1. Oosterlinck W, Lobel B, Jakse G, et al. Guidelines on bladder cancer. Eur Urol. 2002;41:105. 2. Salvador R, Vilana R, Bargalio X, et al. Tuberculous epididymo-orchitis after intravesical BCG therapy for superficial bladder carcinoma. J Ultrasound Med. 2007;26:671Y674. 3. Chung J, Kim M, Lee T, et al. Sonographic findings in tuberculous epididymitis and epididymo-orchitis. J Clin Ultrasound;25:390Y394. 4. Demers V, Pelsser V. BCGitis: a rare case of tuberculous epididymo-orchitis following intravesical bacillus Calmette-Guerin therapy. J Radiol Case Rep. 2012;6:16Y21. 5. Kim SH, Pollack HM, Cho KS, et al. Tuberculous epididymitis and epididymo-orchitis: sonographic findings. J Urol. 1993;150:81Y84. 6. Yang D, Kim SH, Kim HN, et al. Differential diagnosis of focal epididymal lesions with gray scale sonographic, color Doppler sonographic, and clinical features. J Ultrasound Med. 2003;22:135Y142.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
