Case Presentation: A 33-year-old male with a past medical history of gout presented with a 5-day history of intermittent fevers, arthralgias, testicular pain and swelling. He denied dysuria, penile discharge, lymphadenopathy, and rashes. He reported having 3 female sexual partners over the past 6 months with consistent condom use and no history of sexually transmitted infections (STIs). On presentation, he was febrile (38.1°C), tachycardic (130 beats per minute), and normotensive (125/71 mmHg). Physical exam revealed an edematous and tender right testicle, without overlying skin changes, inguinal lymphadenopathy, erythema, or penile discharge. The white blood cell count was 9.1 K/cumm. Urinalysis and STI screening tests were negative. Blood cultures were obtained. A scrotal ultrasound (US) showed evidence of epididymo-orchitis and a 1.1 cm right testicular abscess. Piperacillin-tazobactam was given. The patient deferred incision and drainage of the abscess and opted for antibiotic management alone. He was discharged with trimethoprim/sulfamethoxazole and urology follow-up. Post-discharge, blood cultures grew gram-negative coccobacilli, and the patient was called back for further evaluation. He reported subjective fevers and worsening of testicular swelling since discharge. Repeat US showed an interval abscess increase to 1.5 cm. However, the abscess was not amenable to drainage. The patient was given a dose of ceftriaxone and discharged on ciprofloxacin per urology recommendations. Blood cultures were later identified as Brucella melitensis. The patient was subsequently seen in the infectious disease clinic, where he reported exposure to animals on a ranch in Mexico more than 20 years ago. He denied consumption of unpasteurized products. He more recently worked as a cargo handler at an airport where he may have had exposure to animal products. The patient was transitioned to doxycycline and rifampin for 6 weeks. On completion of therapy, he reported full resolution of symptoms. Repeat US showed complete resolution of the abscess.
Discussion: Brucella species are gram-negative coccobacilli. Transmission to humans can occur through direct contact with an infected animal, through inhalation of aerosolized organisms from animal products (e.g. abattoir), or through consumption of unpasteurized milk products or undercooked meat. It is proposed that our patient was exposed to animal products while working as a cargo handler; however, this is not confirmed. Brucellosis typically presents as non-specific symptoms including fevers, myalgias, arthralgias, and fatigue. Genitourinary (GU) brucellosis occurs in 2-20% of patients with brucellosis and frequently affects young adult males.1 Epididymo-orchitis is the most frequent GU manifestation of brucellosis and can present as unilateral scrotal pain, swelling and fever.2 Definitive diagnosis involves isolation of Brucella species from either abscess aspirate or blood cultures.3 In our case, it took time for blood cultures to speciate and provide a diagnosis. Antimicrobial therapy, typically with doxycycline and rifampin, for 6-8 weeks has been recommended to prevent recurrence and complications such as testicular necrosis and infertility.4
Conclusions: Brucellosis is relatively uncommon in the United States and thus may lead to delays in diagnosis. This case highlights the importance of considering brucellosis in patients with worsening GU symptoms despite antibiotic compliance who are found to have gram-negative coccobacilli bacteremia.