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“Granulomatous Epididymitis” possibly due to TB
By
Bijan Sadrifrom Tehran University of Medical Sciences
Dr. Gillian LiebermanHarvard Medical School
November 2001
2
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
3
• 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:
4
Past Medical History:• Bilateral inguinal hernia repair
during childhood• Left orchiectomy.(Complication
of hernial repair) • Mesh in the right inguinal canal
for his hernia
5
Examination:
• Sinus tract at the lower portion of scrotum that tracks to the lower portion of testicle
• Testicle itself not involved
6
Social History:
• The patient claims that ejaculation relieves the sensation of pressure and pain
• May have high risk behavior
7
Plan:
•Testicular U/S• Resection of the scrotal
sinus tract
8
Anatomy: Normal Testis
Head
BodyTail
9
Anatomy: Normal Testis
10
Our Patient: Testicular Ultrasound
• The right testis: normal in size, echogenicity and vascular flow.
Courtesy of Dr. Robert Kane
11
Our Patient: Testicular Ultrasound
• The right testis: normal in size, echogenicity and vascular flow.
Courtesy of Dr. Robert Kane
12
Our Patient: Testicular Ultrasound
• The right testis: normal in size, echogenicity and vascular flow.
Courtesy of Dr. Robert Kane
13
Our Patient: Epididymal Ultrasound
• The right epididymis: abnormal in thickness and echogenicity
Courtesy of Dr. Robert Kane
14
Our Patient: Epididymal Ultrasound
• The right epididymis: abnormal in thickness and echogenicity
Courtesy of Dr. Robert Kane
15
Our Patient: Epididymal Ultrasound• The head and
body of the epididymis: hypoechoic, relatively homogeneous appearance suggesting microtubular dilatation.
Courtesy of Dr. Robert Kane
16
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
17
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
18
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
19
Our Patient: Scrotal Ultrasound
• Multiseptated loculated hydrocele along the medial hemiscrotum contiguous to the enlarged epididymis.
Courtesy of Dr. Robert Kane
20
Our Patient: Scrotal Ultrasound
• Multiseptated loculated hydrocele along the medial hemiscrotum contiguous to the enlarged epididymis.
Courtesy of Dr. Robert Kane
21
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
22
Our Patient: Scrotal Ultrasound
• Fistulous tract can be followed directly into the enlarged and abnormal epididymal tail.
Courtesy of Dr. Robert Kane
23
Our Patient: Scrotal Ultrasound
• Fistulous tract can be followed directly into the enlarged and abnormal epididymal tail.
Courtesy of Dr. Robert Kane
24
Diagram of abnormalities:
Head
BodyTail mass
Hydrocele
Dialated Head and Body
Fistula
25
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
26
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
28
The Disease Is Chronic
29
Loculated hydrocele
Old Abscess
30
The pathogen caused erosion and fistula to the
skin
31
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(?)
32
Plan:
• Resection of the Sinus Track of the Scrotum
• Antibiotics
33
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
36
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.
37
Acknowledgements:
Robert Kane, MDGillian Lieberman, MDMs. Pamela Lepkowski
Larry Barbaras and Cara Lyn d’amour