Emphysematous epididymo-orchitis: A case report with review of literature
Emphysematous epididymo-orchitis on right side
A 44-year-old male patient presented to the emergency department of our hospital with an acute onset pain and swelling of the right scrotal sac with pyuria for seven days. He had no history of any co-morbidities like diabetes and hypertension. There was no history of trauma. On examination, he was febrile with a temperature of 101 degrees. Right testis was enlarged with redness of overlying scrotal skin.On palpation revealed an enlarged, tender right testis and the epididymis.
The patient underwent ultrasound of scrotum, which showed an enlarged right testis with an ill-defined heterogeneous lesion in right testis involving its upper half measuring approx 25x25mm with posterior acoustic shadowing [figure 1].Rest of the testis showed no vascularity. Right epididymis was bulky with a small collection measuring approx 1x1cm surrounding it [Figure 2]. Right epididymis also showed a mild increase in vascularity on colour Doppler. The left testis was normal in size, shape and echotexture [figure 3]. Findings of ultrasound were confirmed on non-contrast computed tomography of the pelvis and scrotum, which shows enlarged and hypodense appearing right testis with multiple large air foci within [Figure 4].The seminal vesicles were normal, and there was no evidence of any diverticulitis on NCCT.The diagnosis of emphysematous epididymo orchitis was made. The patient was started on broad-spectrum antibiotics and underwent right orchidectomy and surgical debridement. Extensive inflammation was seen in the scrotum with gas bubbles, extending through the tunica into the substance of the right testis was found during surgery. Patient symptomatically improved after surgery and discharged from hospital.
Etiology and demography Emphysematous epididymo-orchitis is a rare cause of the acute scrotal emergency. It is an acute inflammatory condition of the scrotum with the presence of air within. Only a few cases have been reported in the literature so far. This entity usually starts as epididymitis which begins in the tail of the epididymis and spreads further to involve the testis also. Pathogenesis of conversion of epididymo-orchitis to emphysematous orchitis is still unclear. Diabetes mellitus is a predisposing condition. Two case reports of emphysematous orchitis occurring as a complication of sigmoid diverticulitis and HIV infection have been reported so far [1, 2]. Most common pathogens responsible for are gas-forming infection are E. coli, Klebsiella, Pseudomonas, Streptococci, Staphylococci and Bacteroides. Clinical features and imaging findings The patient may present with acute onset scrotal pain, fever, pyuria and dysuria. Predisposing conditions like diabetes mellitus may be present. On examination, the scrotum will be enlarged and tender with erythema of overlying skin. Clinical diagnosis of emphysematous orchitis is difficult. Ultrasound is the first investigation of choice for scrotal diseases. Ultrasound may show enlarged testis with altered echotexture. Multiple air foci in the testis may appear as small bright hyperechoic foci with distal acoustic shadowing. These air foci will exhibit a change in position when pressure is applied with the transducer. CT is highly sensitive and confirmatory imaging modality for the diagnosis of emphysematous orchitis. CT scan of the scrotum will show multiple large air foci with low HU values. CT scan will help to identify scrotal hernia with bowel as content by observing its continuation with the intra abdominal bowel loops apart from the displacement of the scrotal structures and bilateral normal-appearing testes .MRI can also be used to detect complications arising out of this entity since it has better soft-tissue contrast resolution. Radiography has a minimal role in the diagnosis of emphysematous orchitis.It may show any calcification. Complications Emphysematous epididymo-orchitis may extend to the skin and superficial layers of the scrotum leading to complications that include cellulitis, which in turn can predispose to Fourniers gangrene which is a rare and fatal fulminant necrotizing fasciitis of the penis, scrotum and perineum. Treatment and prognosis According to the currently available literature, early diagnosis and treatment with broad-spectrum antibiotics and orchidectomy with surgical debridement provide an excellent prognosis.
• Emphysematous epididymo orchitis should be considered in the differential diagnosis of acute scrotal pain. • Ultrasound is the primary investigation of choice, and diagnosis can be confirmed by NCCT. • Early diagnosis, vigorous antibiotic treatment and surgery lead to excellent prognosis.