Brucellar testicular abscess: The 17^th case report and review of literature

Abstract

Brucellosis is an endemic zoonotic disease caused by intracellular gram-negative coccobacilli called Brucella. This infectious disease may implicate many farm animals and is transmissible to exposed humans. Brucellosis is potentially life-threatening and may lead to granulomatous multi-organ involvement with tendency to chronicity and recurrence. The treatment of brucellosis requires combined and protracted antimicrobial therapies to eliminate the disease and to avoid its relapse. Genitourinary brucellosis is common among infected humans in endemic areas and is considered the second-most affected focal site, which commonly manifests as epididymo-orchitis. Testicular abscess, however, is an extremely rare complication of brucellosis. To the best of our knowledge, in the literature, there are to date only 16 previously published case reports, including 22 patients of brucellar testicular abscesses, emphasizing the extreme rarity of this condition. Most of these cases harbored small abscesses, which were treated conservatively using antibiotics therapy only, or with added drainage of the abscesses. Larger abscesses were reported to necessitate orchiectomy. In some cases, the abscesses were mimicking tumors, and surgeries for orchiectomy were done accordingly. A summary of the previously reported cases in the literature is presented. Here, we present the 17^th case report of a 34-year-old man with a right-side huge multilocular brucellar testicular abscess apparently replacing the entire testicle, who was successfully treated with organ-sparing management by incision-drainage of the large abscess with antibiotics, to eventually preserve his testis. In conclusion, brucellosis should be considered among the differential diagnoses of any testicular swelling, especially in endemic areas. Drainage of brucellar testicular abscess with appropriate medical treatment is feasible and may preserve the testicle, even with large abscess apparently replacing the entire testicle.

INTRODUCTION

Brucellosis is a zoonotic disease caused by intracellular gram-negative coccobacilli bacteria called Brucella.[1] Brucella can infect many farm and dairy animals such as cows, sheep, and camels. The disease is infectious and can be transmitted to humans by ingesting unpasteurized dairy products or other infected food, or due to exposure to infected animal products.[2] Brucellosis is considered an endemic disease mainly in the Mediterranean and the Arabian regions.[3] According to an epidemiological study that was conducted in Saudi Arabia in 1997, an incidence of approximately 34 cases/100,000 persons was reported, with 1.8:1 male: Female ratio and a mean age of 33.8 ± 13.9 years.[4] The most common Brucella species that are reported to infect humans include Brucella melitensis, Brucella suis, Brucella canis, Brucella abortus, and Brucella neotomae. Brucellosis is a potentially life-threatening multi-organ granulomatous disease that has a variety of clinical manifestations ranging from fever and flu-like symptoms such as arthralgia, myalgia, low back pain, and fatigue, to more chronic manifestations of hepatitis, orchitis, arthritis, encephalomyelitis, and/or endocarditis.[1,2] Brucellosis tends to chronicity and relapse and requires combined and prolonged antimicrobial therapies to control the disease and to avoid the recurrence.[2] Genitourinary brucellosis is common among infected humans in endemic areas, and considered the second-most affected site, which commonly manifests as epididymo-orchitis.[2]

Testicular abscess, however, is an extremely rare complication of brucellosis. To the best of our knowledge, in the literature, there are to date only 16 previously published case reports of brucellar testicular abscess, including 22 patients[5-20] [Tables 1 and 2], emphasizing the extreme rarity of this condition. Most of these cases harbored small abscesses, which were treated conservatively using combined antibiotics, with or without drainage of the abscesses. Larger abscesses were reported to necessitate orchiectomy. In some cases, the abscesses were mimicking tumors, and surgeries for orchiectomy were done accordingly. In this article, we present the 17^th case report of a 34-year-old man with a right-side huge multilocular brucellar testicular abscess apparently replacing the entire testicle, who was successfully treated with organ-sparing management by incision-drainage of the large abscess with combination of antibiotics, to eventually obviate the need for orchiectomy and safely preserve his testis. In addition, a summary of the previously reported cases in the literature[5-20] is also presented [Tables 1 and 2].

Table 1.

Summary of previous 13 case reports and the pertinent data of our case

Study (publication year)	Age, duration of symptoms	Exposure	Clinical findings	US/MR findings	Brucella agglutinin titer	Culture of abscess	Histopathology	Antimicrobials therapy	Intervention
Fernández Fernández et al.,1990[5]	ND 2 months	ND	Testicular pain and swelling. Coexisting systemic brucellosis	Increased testicular size with intratesticular abscess	ND	Negative	Abscess	Double drug	Orchiectomy, due to progression
Castillo Soria et al., 1994[6]	ND ND	ND	ND	Large abscess. Complete destruction of the testis	ND	Negative	Abscess	Double drug	Orchiectomy, due to complete destruction of the testis
Bayram and Kervancioğlu 1997[7]	ND ND	ND	ND	Hypoechoic tumor-like lesion with size of 23 mm	Positive	B. melitensis	Abscess	D and R for 6–8 week after orchiectomy	Initial orchiectomy, as tumor was suspected
González Sánchez et al., 1997[8]	ND ND	ND	Left testicular pain and swelling. History of systemic brucellosis 4 months earlier	Diffuse enlargement of the left testis with hypoechoic areas	Positive	ND	CGI	Double drug	Orchiectomy, due to poor response to therapy
Kocak et al., 2004[9]	32 years 2 months	ND	Left painless testicular mass. History of systemic brucellosis 3 years earlier	Hypoechoic heterogeneous intratesticular mass measuring 63 mm×42 mm×38 mm	Positive	Negative	CGI	C and D for 6 week, after orchiectomy	Initial orchiectomy as tumor was suspected
Akinci et al., 2006[10]	ND ND	ND	ND	Hypervascularity with testicular abscess. Size was not specified	Positive	B. melitensis	NGO	D+R for 6–8 week	Orchiectomy
Koc et al., 2007[11]	42 years 6 weeks	Ingestion of unpasteurized cheese	Right testicular pain and swelling, fever, and night sweats	Thick-walled abscess measuring 55 mm × 50 mm × 40 mm	Positive	B. melitensis	CGI	D and R for 4 months after drainage	Abscess drainage
Yemisen et al., 2012[12]	42 years 2 weeks	Teacher working in small villages	Right scrotal pain and swelling, fever, fatigue, and diffuse arthralgia	Hypoechoic cystic lesion measuring 20 mm × 15 mm	Positive	Negative	No biopsy	D and R for 6 weeks After 5 months, a heterogeneous, hypoechoic lesion 13 mm × 7 mm was considered healed infective tissue In later follow-up, no new changes were detected	No successfully treated with antimicrobials only
Kaya et al., 2015[13]	23 years 2 months	Ingestion of unpasteurized cheese	Right testicular swelling	Anechoic cystic lesion measuring 31 mm × 41 mm × 74 mm with hypervascularization in the testis and epididymis	Positive	Negative	No biopsy	D and S for 7 days, but no response, so it was drained using FNA, followed by D and R for 6 weeks After 2 months, US showed complete resolution of the lesion leaving a residual small area of heterogeneity in the right testis	FNA drainage
Tahaineh et al., 2015[14]	36 years 6 weeks	Ingestion of raw milk.	Left testicular pain. History of systemic Brucella with fever and rigors treated 3 months ago	Multiple parenchymal irregular anechoic cystic areas with thin internal septations and increased vascularity of the left testis. Size was not determined	Positive	B. melitensis	No biopsy	D, C, and B for 3 months US at 4 weeks showed marked reduction in size of abscesses as the largest one measured 4 mm in diameter	No (FNA was unsuitable due to multiplicity and small size of abscesses)
Vallianou et al., 2018[15]	66 years 2 weeks	Consumption of unpasteurized milk. Working with farm animals. Endemic area	Scrotal pain and edema, fever (39°C), weight loss. Tender right testis	Nonvascular hypoechoic areas (abscesses) and slightly hypervascular testis. Size was not determined	Positive	B. melitensis	No biopsy	G for 8 days with D and R for 8 weeks Disappearance of the testicular abscesses at 8 weeks	No
Kazaz et al., 2019[16]	42 years ND	Feeding sheep and consuming cheese prepared from raw milk	Left testicular pain and swelling	2 thick-walled, hypoechoic clusters measuring 25 mm×15 mm and 12 mm × 7 mm with peripheral vascularity (abscess), in the lower pole of the left testicle	Positive	B. melitensis	Abscess	D and R for 6 weeks, after drainage	Drainage
Gozdas and Bal 2020[17]	ND ND	Have risk factor for brucellosis	Scrotal pain, swelling and enlarged tender testis	Testicular abscess and reactive hydrocele	Positive	ND	ND	Combination antibiotics	Surgical drainage in addition to medical treatment
Present case (2022)	34 years 3 months	Shepherd, close contact to cattle. Systemic brucellosis few weeks earlier	Right scrotal swelling and pain	Large, (7.5 cm×4.5 cm×4 cm), heterogenous multilocular mass almost replacing the entire right testis and epididymis with central liquified necrosis and apparently compressed vascularized peripheral testicular tissue, surrounded by thickened scrotum	Positive	Negative	Necrotic testicular tissue with granulation tissue and dense inflammation and abscess formation	Ceftriaxone for 6 weeks + ST for 6 months + R for 6 months	Incision and drainage Despite the large abscess size, no orchiectomy is needed

US: Ultrasonography, CDUS: Color Doppler ultrasonography, CGI: Chronic granulomatous inflammation, NGO; Necrotizing granulomatous orchitis, D: Doxycycline, R: Rifampicin, S: Streptomycin, C: Ciprofloxacin, G: Gentamicin, ST: Sulfamethoxazole and trimethoprim, ND: Not defined, FNA: Fine needle aspiration, BEO: Brucellar epididymo-orchitis, MR: Magnetic resonance, B. melitensis: Brucella melitensis

Table 2.

Summary of three additional previously published reports on brucellar testicular abscesses, including nine cases

Study (year of publication)	Number of cases	Case summary	Treatment
Salmeron et al., 1998[18]	2	Report on two cases of abscesses seen among seven cases of BEO with age of 27 and 34 years Both cases are residing in endemic areas The period between initial US diagnosis of BEO and diagnosis of abscess was 1 and 3 months, despite compliance to specific therapy US findings were described in one of the cases as: “anechoic lesion with acoustic enhancement and debris” Positive serologic tests in both cases	Specific antimicrobial therapy for both cases (no further details on medical therapy) One case underwent orchiectomy after 13 months of medical treatment, due to recurrent episodes of BEO and abscess The other case underwent epididymectomy after 8 months of medical treatment, due to poor response to medical therapy. The testis showed resolution in successive US scans; hence, no orchiectomy was done
Petik 2016[19]	3	Case 1: A 26-year-old man with right scrotal swelling, pain, and redness US demonstrated a cystic lesion about 4 cm with thick wall, septations, and solid components MRI showed right intratesticular cystic thick-walled lesion (hypointense in T1-weighted and hyperintense in T2-weighted images), with marked wall enhancement after IV gadolinium injection Wright test was positive at 1/1280 titer Case 2: A 23-year-old man with left scrotal swelling, pain, and redness MRI showed a cystic lesion with heterogeneous signal intensity, and thick wall is seen within the left testicle in T1- and T2-weighted images; with wall enhancement after IV gadolinium injection Wright test was positive at 1/160 titer Case 3: A 24-year-old man with painless right scrotal swelling US demonstrated right testicular enlargement and diffusely hypoechoic nodular appearance MRI showed the right testis appearing slightly hyperintense in T1-weighted and hypointense in T2-weighted images, when compared with the left side, with strong enhancement after IV gadolinium injection Wright test was positive at 1/320 titer	All patients were treated with antibiotic therapy and abscess drainage
Baykan et al., 2019[20]	4	Report on four cases of testicular abscesses seen in US of 24 cases with BEO US findings were described one case only as: “a thick-walled testicular abscess accompanied by a hypoechoic heterogenous appearance of the neighboring testicular parenchyma in a 38-year-old case”	Medical treatment was applied to all patients In two cases, US-guided abscess drainage was also performed Orchiectomy was performed in one case due to unresponsiveness to the medical treatment

US: Ultrasonography, BEO: Brucellar epididymo-orchitis, IV: Intravenous, MRI: Magnetic resonance imaging

CASE REPORT

Our patient is a 34-year-old, otherwise healthy, Sudanese male residing in the Saudi Arabia, married with one child, and who has used to be a shepherd in a lifelong close contact to sheep and cattle and their products. He was in his usual good health state until he started to develop an onset of fever, night sweating, loss of appetite, fatigue, and multiple joint pains. He has initially sought medical advice in other health facility, where he was diagnosed as brucellosis based on a positive serum agglutination test at 1:320 titer. The patient has received oral doxycycline 100 mg twice daily for 30 days and streptomycin 1-g intramuscular injections for 21 days. A few days later to the onset, despite ongoing receiving the medications, he started to develop a right scrotal swelling, for which he revisited his treating physician who advised that this swelling should regress with the treatment. The patient claimed no history of urinary symptoms, no urethral discharge, and no exposure to sexually transmitted diseases (STDs). All the symptoms have faded away after 2 weeks of treatment, except the right scrotal swelling, which progressively continued increasing in size and becoming more painful, despite completing the treatment as prescribed. The patient did not seek any further medical advice until the right scrotal pain was bothering; then, he first presented to our outpatient clinic after 3 months of the onset.

On examination, the patient looked comfortable, not in apparent acute pain, and was vitally stable with normal temperature. Scrotal examination [Figure 1] has shown a large, measuring about 12 cm × 8 cm × 6 cm in external dimensions, moderately tender, and fluctuant right scrotal swelling, with an overlying hot erythematous edematous attached scrotal skin. The right epididymis was not separable from its mate testicle. No clinical abnormalities were detected in the contralateral testicle and epididymis, or spermatic cords. No inguinal or abdominal lymph nodes or other masses were clinically detectable. The patient was admitted to our hospital as a case of possible right brucellar testicular abscess.

Figure 1.

Gross appearance of the scrotum at the time of admission showing large right scrotal swelling, about 12 cm × 8 cm × 6 cm in dimensions, with an overlying hot erythematous edematous attached scrotal skin

Scrotal ultrasonography at admission [Figure 2] has shown a large (7.5 cm × 4.8 cm × 4 cm) heterogenous multilocular mass that is almost replacing the entire right testis and epididymis. The mass demonstrated central liquified necrosis and apparently compressed vascularized testicular tissue at the mass periphery. The surrounding tunica albuginea was thickened and hyperemic, with tunical defect communicating with right side scrotal abscess fluid, which was covered by intact thickened scrotum.

Figure 2.

Scrotal ultrasound at presentation has shown a large (7.5 cm × 4.8 cm × 4 cm) heterogenous multilocular mass that is almost replacing the entire right testis and epididymis with central liquified necrosis (a and b), and apparently compressed vascularized testicular tissue at the periphery (arrow) with surrounding thickened scrotum (c)

Computed tomography (CT) scan with contrast [Figure 3] has similarly demonstrated a large (6 cm × 4.5 cm × 3.7 cm) right testicular multilocular hypoattenuation mass with peripheral enhancement and surrounding scrotal thickening, reporting right testicular abscess.

Figure 3.

Images of CT with contrast at presentation showing right testicular large multilocular hypoattenuation mass with peripheral enhancement and surrounding scrotal thickening, with size of 6 cm × 4.5 cm × 3.7 cm (a-c). CT: Computed tomography

The infectious disease (ID) department has been consulted for further assessment and comanagement. On the day of admission, the patient showed positive Brucella antibody titers (1:320), mild leukocytosis (12.9 K/μL; reference range: 4.5–11.5 K/μL), and elevated C-reactive protein (CRP) (88.1 mg/L; reference range: 0–3 mg/L), with normal renal and hepatic functions. In addition, the ID team requested lumbar puncture for cerebrospinal fluid (CSF) examination and echocardiogram, which ruled out neurobrucellosis and brucellar endocarditis, respectively. Staining for acid-fast bacilli in urine and CSF was negative. Cultures of urine, CSF, and blood were as well negative for any organism, including Brucella, tuberculosis, and fungi. In addition, testicular tumor markers were also unrevealing. Table 3 summarizes the relevant laboratory results on the day of admission and during the hospital stay, before and after abscess drainage. The ID team prescribed ceftriaxone 2-gram injections every 12 h for 6 weeks, trimethoprim-sulfamethoxazole 2 double-strength tablets PO every 12 h for 6 months, and rifampicin 900 mg daily PO for 6 months.

Table 3.

Summary of the laboratory results on admission and during hospital stay, before and after abscess drainage

Test	Sample	Patient’s value	Reference value	Comment
Before abscess drainage
Sodium	Serum	137 mmol/L	136–145 mmol/L	Normal
Potassium	Serum	4 mmol/L	3.5–5.1 mmol/L	Normal
Chloride	Serum	102 mmol/L	98–107 mmol/L	Normal
Urea	Serum	3.6 mmol/L	3.2-8.2 mmol/L	Normal
Creatinine	Serum	68 µmol/L	61.9–114.9 µmol/L	Normal
PT	Serum	12.3 s	9.4–12.5 s	Upper normal
APTT	Serum	28.5 s	25.1–36.5 s	Normal
Total protein	Serum	78 g/L	57–82 g/L	Normal
Albumin	Serum	47 g/L	40.2–47–6 g/L	Upper normal
Alkaline phosphatase	Serum	79 U/L	46–116 U/L	Normal
Aspartate amino transferase	Serum	21 U/L	<34–118 U/L	Normal
Alanine amino transferase	Serum	21 U/L	10–49 U/L	Normal
Gamma glutamyl transferase	Serum	20 U/L	5 to 40 U/L	Normal
Total bilirubin	Serum	14 µmol/L	5–21 µmol/L	Normal
First day of admission	Blood	12.9 K/µL	4.5–11.5 K/µL	Mild elevation
Automated neutrophils (K/uL)	Blood	10.45 K/µL	2–7.5 K/µL	Abnormally high
Automated neutrophils (%)	Blood	81	50–70	Abnormally high
Hemoglobin	Blood	14.4 g/dL	14–18 g/dL	Normal
RBCs	Blood	5.19 K/µL	4–6 K/µL	Normal
Platelets	Blood	384 K/µL	150–450 K/µL	Normal
CRP	Serum	88.1 mg/L	0–3 mg/L	Abnormally high
Brucella antibodies	Serum	Positive	1:320	Positive
Urinalysis	Urine	Negative for ketones, proteins, glucose, nitrite, and pyuria		Normal
Stain for acid-fast bacilli (TB)	Urine CSF	Negative	Negative	Normal
Cultures	Urine blood CSF	All negative for: Nonspecific bacteria, Brucella, TB, and fungi	Negative	Normal
Protein	CSF	0.376 g/L	0.15–0.6 g/L	Normal
Glucose	CSF	3.6 mmol/L	2.3–4.1 mmol/L	Normal
Alpha fetoprotein	Serum	4.22 ng/mL	0–8.7 ng/mL	Normal
B-hCG	Serum	<2.30 IU/mL	0–2.90 IU/mL	Normal
LDH	Serum	236 U/L	120–246 U/L	Normal
Postdrainage
Culture	Drainage	Negative for all organisms	Negative	Normal
Stain for acid-fast bacilli (TB)	Drainage	Negative	Negative	Normal
WBC	Blood	7.2 K/µL	4.5–11.5 K/µL	Normal
CRP	Serum	4.27 mg/L	0–3 mg/L	Improved

WBC: White blood cells, RBC: Red blood cells, CRP: C-reactive protein, B-hCG: B human chorionic gonadotropin, LDH: Lactate dehydrogenase, TB: Tuberculosis, CSF: Cerebrospinal fluid, PT: Prothrombin time, APTT: activated partial thromboplastin time

The patient, in addition to the medical treatment of brucellosis, was counseled on the surgical options of incision and drainage of the large abscess with attempting preservation of the testicle versus orchiectomy. The patient has then undergone incision and drainage of the abscess under local anesthesia, which was followed by partial improvement of both pain and swelling. Yet, follow-up scrotal ultrasound has shown residual abscess locule measuring 3.5 cm × 2.7 cm, which necessitated a repeat more effective second incision-drainage under general anesthesia and ultrasound guidance. The patient has substantially clinically improved after the second drainage, as the pain was markedly resolved, the leukocytosis was normalized (7.2 K/μL), and CRP gradually declined to 4.27 mg/L. The abscess drainage fluid yielded no organism on all cultures, while the stain for acid-fast bacilli was negative as well. Moreover, a sample was sent for histopathologic examination, which showed necrotic testicular tissue with granulation tissue and dense inflammation and abscess formation. The patient was discharged from the hospital in a good condition and was instructed to continue receiving the medications as prescribed.

The patient was regularly followed up in both urology and ID clinics for 3 months after drainage at the time of writing the present report. The patient was showing compliance to medications, and his symptoms have tremendously improved, with normalization of all laboratory findings, including serum Brucella antibodies test at 3 months. Physical examination of the scrotum at 9 weeks [Figure 4a] demonstrated resolution of swelling and edema, healing of the abscess, and improvement of size and consistency of the right testicle to be almost equivalent to the normal contralateral testicle, with residual granulation tissue at the site of skin incision, which healed at 12 weeks after drainage [Figure 4b and c]. Scrotal ultrasonography [Figure 5] and CT scan [Figure 6] were repeated at 2 months after the drainage, which showed a remarkable reduction of the size of the healing abscess and preserved testicular vascularity, with residual small (1.3 cm × 1.6 cm × 1.6 cm) intratesticular heterogeneous focal lesion mostly representing a healing granulation tissue. At 36 weeks following the second drainage, the patient has contacted our urology team over the phone from abroad, to inform that he is doing well, and his wife has got pregnant, with no further information.

Figure 4.

Gross appearance of the scrotum at 9 weeks (a) and 12 weeks (b and c), demonstrating the resolution of the swelling and edema, healing of the abscess, and improvement of size of the right testicle to be almost equivalent to the normal contralateral testicle, with residual granulation tissue at the site of skin incision at 9 weeks which healed at 12 weeks after drainage

Figure 5.

Scrotal ultrasound 2 months after drainage, showing remarkable reduction of the size of the right testicular abscess and intact vascularity of the testis with residual small intratesticular heterogenous focal lesion appearing as a healing inflammatory tissue (a-d)

Figure 6.

CT with contrast 2 months after drainage, showing a significant reduction of the size of the right testicular abscess, measuring 1.3 cm × 1.6 cm × 1.6 cm. CT: Computed tomography

Literature search

To find out similar previously published reports on brucellar testicular abscesses, a literature search was conducted till December 2021 using PubMed database (National Library of Medicine, Washington, DC) and different combinations of the following key words and mesh terms: (a) “brucellar testicular abscess,” (b) “(brucellosis) AND (testicular abscess),” and (c) “(testicular diseases AND brucellosis).” The search has yielded only 16 published case reports.[5-20]

DISCUSSION

Brucellosis is an infectious zoonotic disease endemic in many geographic regions of the world, including Saudi Arabia, that has been known to be transmissible to exposed humans.[3,4] The most reported Brucella species in humans is B. melitensis,[1,2] which was also the incriminated organism in six of the reports of brucellar testicular abscesses.[7,10-11,14-16] Brucellosis is a potentially life-threatening multi-organ disease that may involve many organs, including heart, liver, brain, bones, joints, and testis. The disease has variable manifestations, that most commonly include fever, sweating, fatigue, bones and joints pain, painful lymphadenopathy, and possibly murmurs in case of cardiac involvement.[1,2] Involvement of the genitourinary system in brucellosis is common, and is considered the second-most affected focal site, which usually manifests as epididymo-orchitis or nephritis.[2]

Brucellar testicular abscess is an extremely rare complication, and to the best of our knowledge, there are merely 16 previously published case reports in the literature,[5-20] involving 22 patients. Testicular abscess due to brucellosis was first described in the literature in 1990 by Fernández Fernández et al.[5] Their patient has had a history of coexisting systemic brucellosis and scrotal swelling, similar to our patient. The abscess may ensue and progress despite effective medical therapy as in our patient. The pertinent data of the 16 previously published case reports are summarized in Tables 1 and 2.

The diagnosis of brucellosis is usually based on either elevated serum antibody titer or positive culture, or both. The differential diagnosis of brucellar testicular abscess includes brucellar epididymo-orchitis, nonspecific epididymo-orchitis, tuberculosis, and necrotizing testicular tumors. In our patient, the diagnosis of brucellosis and brucellar testicular abscess was based on the constellation of the typical history of intense occupational exposure to animals in endemic region, lack of history of previous urinary tract infections or STDs exposure, and more specifically, the high Brucella antibody titer. The clinical picture of huge abscess with disproportional less pain and tenderness, lack of high fever, mild leukocytosis, negative tuberculosis workup, negative tumor markers, the scrotal ultrasonography and CT imaging findings, were additional diagnostic clues. Nevertheless, in our patient, cultures of urine, blood, CSF, and abscess drainage were all negative for Brucella and any other organisms, which may be due to the suppressive effects of the received antibiotics.

The literature review revealed that there was no universal treatment has been applied to all patients with brucellar testicular abscesses in the published case reports[5-20] [Tables 1 and 2]. Nevertheless, receiving a variety of combinations of antibiotics for variable prolonged periods of time was the common theme in all reported cases. Many of the cases have harbored small abscesses, which were treated conservatively with antibiotics only, or with added drainage. On the other hand, larger abscesses have necessitated orchiectomy. The patients in three reports[12,14-15] were treated exclusively with medications. Two of them reported hypoechoic abscesses,[12,15] while one report specified the size of a small abscess, which was 20 mm × 15 mm.[12] Three reports[11,13,16] have determined moderate-sized abscesses, with dimensions of 55 mm × 50 mm × 40 mm, 31 mm × 41 mm × 74 mm, and 25 × 15 with 12 mm × 7 mm, respectively, which were treated with antibiotics in addition to drainage. Among those cases, one case showed anechoic lesion,[13] while another study reported hypoechoic clusters with peripheral vascularity.[16] Abscess drainage has supplemented antibiotics in additional four reports[17-20] without specifying the size of the abscesses. In other six reports,[5-10] the patients were initially treated with antibiotics, followed later by orchiectomy, either due to failed medical therapy or progressive enlargement of the abscess,[5,6,8-10] or suspicion of a tumor.[7] Of them, the size was only specified in two cases as 23 mm and 63 mm × 42 mm × 38 mm, respectively,[7,9] while hypoechogenicity was noted in two cases,[7,9] and hypervascularity was seen in only a single case.[10]

In our patient, the brucellar multilocular testicular abscess was considerably larger than the previously reported cases, and the testis was apparently entirely replaced by the abscess with compressed vascularized testicular tissue at the periphery. The ID team proposed the above-mentioned medical therapy of combined antibiotics for up to 6 months duration as they suspected neurobrucellosis, although CSF findings were nondiagnostic. The ID team also aimed to eliminate the systemic brucellosis, to minimize the risk of disease recurrence, and importantly to prevent the involvement of the contralateral testicle. Because of the huge size and characteristics of the abscess and given the rarity of the disease and the lack of standardized treatment, we counseled the patient on performing either surgical drainage of the abscess or orchiectomy, in addition to the antibiotics treatment. A shared decision of incision-drainage with the antibiotics was made and implemented, and has proved successful to achieve full recovery with preservation of the testis in our patient. This organ-sparing management, and obviating the need for orchiectomy, has several positive implications and advantages, with expected positive psychological impact and potential preservation of the hormonal functions of the testis. Nevertheless, despite impregnating his wife, considering the apparent severe damage of the testicular tissue and epididymis, the spermatogenic function of the affected testis and the patency of the epididymis should be markedly jeopardized and questionable.

CONCLUSION

Brucellar testicular abscess is extremely rare. Although the diagnosis is frequently challenging, testicular brucellosis should be considered among the differential diagnoses of any testicular swelling, especially in endemic areas. Here, we present the 17^th case report of a huge multilocular right brucellar testicular abscess which was successfully treated with organ-sparing management, obviating the need to remove the testicle. Drainage of brucellar testicular abscess with medical treatment with appropriate antibiotics is feasible and may preserve the testicle, even with large abscess apparently replacing the entire testicle.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.