ABSTRACT

Brucellar epididymo-orchitis (BEO) is a rare manifestation of brucellosis in pediatric patients and may clinically resemble acute scrotal emergencies such as testicular torsion. A 17-year-old male presented with persistent left testicular pain and fever despite empirical antibiotic treatment. Physical examination revealed tenderness and swelling of the left testis. Laboratory evaluation demonstrated elevated inflammatory markers, while urinalysis and urine culture were unremarkable. Scrotal Doppler ultrasonography demonstrated epididymal enlargement, heterogeneous testicular parenchyma, and increased vascularity. Due to worsening symptoms and inability to exclude testicular torsion, surgical exploration was performed; however, no torsion was identified intraoperatively. Persistent fever despite broad-spectrum antibiotics prompted further investigation. Brucella Coombs agglutination testing was positive at a titer of 1/1280, supporting the diagnosis of brucellosis in the clinical context. Previous antibiotic therapy was discontinued, and targeted treatment with doxycycline and rifampicin was initiated. The patient showed rapid clinical improvement and achieved complete recovery after six weeks of therapy. A narrative literature review was conducted to evaluate previously reported pediatric BEO cases regarding clinical presentation, diagnostic findings, and treatment strategies. Brucellosis should be considered in adolescents presenting with treatment-resistant epididymo-orchitis, particularly in endemic regions. Early serological testing may prevent unnecessary surgical exploration and facilitate timely targeted therapy.

INTRODUCTION

Epididymitis is a common urogenital infection in adolescents and young males and usually responds well to antibiotic therapy⁽¹⁾. However, in treatment-resistant cases, underlying systemic infections should be considered⁽²⁾.

Brucellosis is a zoonotic infectious disease caused by Gram-negative coccobacilli of the genus Brucella, most commonly Brucella melitensis and Brucella abortus. It is transmitted through the consumption of unpasteurized milk and dairy products, undercooked meat, or direct contact with infected animals such as cattle, sheep, goats, and pigs, including exposure to their urine, body fluids, and contaminated reproductive materials^(3-5).

Brucellar epididymo-orchitis (BEO) is a rare but significant complication in children, especially in regions where brucellosis is endemic^{(2, 3, 6)}. Although epididymo-orchitis is the most frequent genitourinary complication, affecting 2-20% of males with brucellosis, its occurrence in children is often underrecognized^{(2, 3, 6)}.

Early recognition is crucial to prevent complications such as abscess formation, infertility, or unnecessary surgical intervention⁽⁶⁾. This study presents a case of treatment-resistant epididymo-orchitis initially managed as non-specific epididymitis but later diagnosed as brucellosis.

CASE REPORT

A 17-year-old male presented to our emergency department with persistent left testicular pain lasting six days. He had previously been evaluated twice at another center and treated with oral antibiotics and anti-inflammatory drugs without improvement.

On admission, the patient was febrile with a temperature of 38.5 °C, heart rate of 110 beats/min, and blood pressure of 100/70 mmHg. Physical examination revealed tenderness and swelling of the left testicle. Laboratory findings showed a white blood cell count of 9,510/µL (4,000-10,000/µL), C-reactive protein level of 51.35 mg/L (0-5 mg/L), aspartate aminotransferase of 49 U/L (0-29 U/L), and alanine aminotransferase of 22 U/L (0-31 U/L). Urinalysis was unremarkable, and urine culture showed no bacterial growth.

Scrotal color Doppler ultrasonography demonstrated enlargement of the left epididymis and a heterogeneous appearance of both the testicular and epididymal parenchyma. The patient, who was a culinary student, reported no clear history of livestock exposure or consumption of unpasteurized dairy products; however, indirect exposure through handling raw animal products during culinary training was considered a possible risk factor.

Due to persistent symptoms, he was hospitalized and started on intravenous ampicillin-sulbactam and amikacin, along with oral ibuprofen. On the third day of hospitalization, persistent fever prompted consultation with the infectious diseases department, and antibiotic therapy was modified. Blood and urine cultures, Brucella serology, and Brucella Coombs agglutination testing were obtained.

On the same day, worsening scrotal pain and swelling led to repeat Doppler ultrasonography, which showed increased vascularity and persistent heterogeneity. Given the discrepancy between clinical findings and imaging, and the inability to exclude testicular torsion, surgical exploration was performed. Intraoperatively, marked edema and enlargement of the testis were observed; however, no torsion was detected (Figure 1).

Despite broad-spectrum antibiotic therapy, fever persisted. On the fifth day, the Brucella Coombs agglutination test returned positive at a titer of 1/1280, while all cultures remained negative. Based on the clinical presentation, epidemiological context, and positive serological findings, brucellosis was considered the most likely diagnosis. Previous antibiotic therapy was discontinued, and the patient was started on doxycycline and rifampicin.

By the eighth day of targeted therapy, the patient’s symptoms had improved significantly. He was discharged with a plan to complete six weeks of treatment, after which full clinical resolution was achieved.

Literature Review

A literature review was conducted to identify previously reported cases of BEO, using PubMed/MEDLINE, Web of Science, Scopus, and TR Dizin databases using combinations of the following keywords: “brucellosis”, “epididymitis”, “epididymorchitis”, and “children”. Two authors independently screened titles/abstracts and full texts; disagreements were resolved by consensus. The search included articles published in English and Turkish up to January 2026. Additional relevant studies were identified through manual screening of reference lists of selected publications. Eligible studies were case reports and case series describing pediatric patients with BEO. In some studies, although pediatric cases were included, patient-specific details could not be extracted as these cases were analyzed together with adult cohorts^{(2, 6-14)}. Data regarding clinical presentation, laboratory abnormalities, therapeutic strategies, and clinical outcomes were extracted. Given the descriptive nature of this review and the heterogeneity of available reports, no formal systematic selection process or quantitative synthesis was performed. Therefore, the review should be interpreted as a narrative overview of reported pediatric cases.

DISCUSSION

Brucellosis is a zoonotic disease that is endemic in developing countries and is still seen in rural areas of developed countries as well⁽⁸⁾. It is highly endemic in Türkiye and more often seen in the Eastern and Southeastern Anatolia Regions, where farming is more pervasive^{(4, 13, 15)}. A history of consuming unpasteurized dairy products or contact with livestock is a key risk factor^{(13, 15-17)}. BEO is thought to occur primarily through hematogenous spread of the organism⁽⁴⁾. Patients may present with a variety of clinical symptoms, with fever and arthralgia being the most common, alongside non-specific findings such as weight loss, night sweats, and abdominal pain^{(2, 17, 18)}. Although epididymo-orchitis is the most common genitourinary involvement of brucellosis—affecting 2-20% of all cases^{(2, 3, 13)}—it is rarely the presenting finding⁽³⁾.

Testicular swelling, scrotal erythema, and fever are the leading features of almost every classical epididymo-orchitis case⁽¹³⁾. While adult cases are typically unilateral, bilateral testicular involvement can also be observed in pediatric patients, particularly in younger children^{(13, 15)}. Notably, unlike non-specific bacterial epididymitis, lower urinary tract symptoms are usually absent, and urinalysis is frequently normal in BEO^{(8, 13)}. Similarly, our patient had a normal urinalysis and sterile urine culture despite significant scrotal inflammation. Furthermore, pediatric BEO can occasionally present alongside unusual complications, such as neurobrucellosis⁽¹⁹⁾, terminal ileitis⁽¹⁾, or pancytopenia⁽²⁰⁾. Because testicular swelling and fever are non-specific findings in epididymo-orchitis, persistent fever despite broad-spectrum antibiotic therapy, together with the endemicity of brucellosis in our region and the patient’s possible exposure to raw animal products during culinary training, prompted consideration of brucellosis.

The differential diagnosis of acute scrotal swelling in children should include tumor, trauma, hematoma, cyst, torsion, and other acute or chronic infections (e.g., abscess, gonorrhea, tuberculosis, mumps, syphilis, or chlamydia)^{(2, 3, 15, 16, 20)}. Besides clinical findings and physical examination, scrotal Doppler ultrasonography, testicular scintigraphy, and magnetic resonance imaging can be used in differential diagnosis^{(2, 3)}. Ultrasonography findings of BEO typically include testicular and epididymal enlargement, heterogeneous echotexture, and hypervascularity^{(3, 13)}. A key challenge in the present case was the differentiation from testicular torsion. Although Doppler ultrasonography demonstrated increased vascularity—favoring an inflammatory process—the progression of symptoms and inconclusive clinical findings necessitated surgical exploration. However, no evidence of torsion was detected intraoperatively. Subsequent serological evaluation supported the diagnosis of brucellosis in the appropriate clinical and epidemiological context, and targeted therapy was initiated. This highlights a critical dilemma in pediatric urology: Balancing the risk of missing torsion against the possibility of unnecessary surgery.

BEO is much less common in children than in adults^{(8, 18)}. In their cohort, Çıraklı et al.⁽⁴⁾ reported that 1.9% of their patients had epididymo-orchitis, and Karaman et al.⁽¹⁷⁾ similarly reported a rate of 1.3%. However, a meta-analysis by Zheng et al.⁽⁵⁾ demonstrated that children remain at a notable risk, with the incidence of BEO being 9% in pediatric male patients. The literature indicates that pediatric BEO is predominantly seen in adolescents, such as a 16-year-old male patient reported by Tanıdır et al.⁽³⁾ who presented to the hospital with left testicular swelling and high fever, or an 18-year-old patient described by Günal et al.⁽¹⁶⁾ with pain and swelling in the left testicle. Nevertheless, it can occasionally affect younger children and toddlers, with reports of BEO in children aged 55 months, 110 months, and 9 years^{(13, 15)}, as well as an 8-year-old immunosuppressed patient with Brucella abortus infection⁽²¹⁾. This review of the literature indicates that most pediatric BEO cases present with unilateral involvement and respond well to medical therapy. Surgical intervention is rarely required when the diagnosis is established early (Table 1).

Early diagnosis and treatment are critical to avoid complications such as testicular abscess, necrotizing orchitis, oligospermia, and azoospermia^{(4, 16)}. The optimal treatment regimen for pediatric brucellosis has not been clearly established and should be individualized according to patient age, disease severity, organ involvement, and drug safety profiles. In children aged 8 years and older, doxycycline combined with rifampicin is commonly recommended, whereas trimethoprim-sulfamethoxazole-based regimens are generally preferred in younger children. The addition of an aminoglycoside, such as streptomycin or gentamicin, may be considered in selected severe or complicated cases but is not routinely required for all patients with BEO^{(13, 15, 22)}.

Most pediatric cases respond well to medical therapy, with surgical intervention (such as orchiectomy) rarely needed if diagnosed early^{(6, 8, 13, 15, 18)}. Delayed or inappropriate treatment, however, can lead to irreversible damage or infertility^{(9, 15, 16, 18)}. Our patient received doxycycline and rifampicin for six weeks, and his symptoms resolved. In endemic regions, early serological testing for Brucella species should be considered in adolescents with epididymo-orchitis who fail to respond to empirical antibiotic therapy.

BEO should be considered in adolescents presenting with treatment-resistant epididymitis, especially in endemic regions. Early serological evaluation may prevent unnecessary surgical exploration and enable timely initiation of targeted therapy, thereby reducing the risk of complications.