A 44-year-old man with a history of recurrent epididymo-orchitis presented to the emergency department complaining of an on-and-off scrotal pain for the last 15 days and low grade fever for which he was given ciprofloxacin for 10 days and acetaminophen (paracetamol) from another hospital. This regimen helped managing his symptoms; however, they were not resolved rendering him seeking medical help at our institution. There were no histories of contact with a tuberculosis patient or raw milk consumption. On physical examination, his scrotum was enlarged, swollen and tender. An ultrasound revealed both testes were of normal size; however, there was bilateral significant increased vascularity in both testicles and both epididymal heads. The scrotal skin was not thickened. There was a slightly increased echogenicity of both testes and a small left hydrocele was identified.
There were a few (about four) tiny echogenic foci noted within the left testicle likely representing small calcifications. Physical examination findings of regional lymph nodes and skin were not significant. While awaiting other investigations, the patient was started on ciprofloxacin 400 mg IV every 12 h as an empiric therapy. Blood culture came back negative for Brucella spp.; however, antibody titers were positive for B. melitensis and B. abortus at 1:1280 for both strains. CRP level was 6.8 mg/L. The patient was diagnosed with Brucella epididymo-orchitis, but refused to undergo lumbar puncture for further investigation. Due to lack of clinical improvement, ciprofloxacin was discontinued three days later and was replaced by ceftriaxone 1 g IV every 12 h, doxycycline 100 mg orally every 12 h and rifampin 900 mg orally once daily. After two doses of 900 mg rifampin, the dose was decreased to 600 mg orally once daily though nothing in the patient's notes indicated the reason for the dose change nor the liver enzymes were elevated. After ten days of treatment, ceftriaxone was stopped and the patient was discharged on doxycycline 100 mg orally every 12 h and rifampin 600 mg orally once daily for a minimum period of three months. Before discharge, the patient was clinically improving as demonstrated by the decreased swelling and tenderness of his scrotum. On his first visit as an outpatient 2 weeks after discharge, the patient reported no new complications and appeared clinically well. Tests showed no signs of drug-induced hepatotoxicity, so the rifampin dose was increased to 900 mg orally once daily. On examination, his scrotum appeared to be relieved of the swelling and decreased in size. CRP level decreased slightly to 5.21 mg/L. A week later, the patient came again for follow up. While the patient did not show up for the next visit, his Brucella epididymoorchitis was deemed cured based on the improved clinical findings and decreased CRP. No repeated serology was done.