Handa et al.

17

Tropical Doctor
2018, Vol. 48(1) 17–20
Granulomatous epididymo-orchitis: ! The Author(s) 2017
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diagnosis by fine needle aspiration sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0049475517711017
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Uma Handa1, Reetu Kundu2, Gunjan Raghubanshi3 and

Vidur Bhalla4

Abstract
Tuberculosis is the leading cause of chronic granulomatous epididymo-orchitis in the Asian population. A retrospective
analysis of 40 patients diagnosed with granulomatous or tubercular epididymo-orchitis on fine-needle aspiration (FNA) was
carried out. May Grünwald giemsa, haematoxylin and eosin and Ziehl Neelsen stained smears were evaluated. Of 40 patients
studied, aspiration smears showed epithelioid cell granulomas with caseation in 17, granulomas alone in 19 and caseation
only in four. Acid fast bacilli were seen in 15. Cytologic diagnoses rendered were tubercular epididymo-orchitis in 15,
granulomatous inflammation suggestive of tuberculosis in six and granulomatous inflammation in 19. FNA may readily
diagnose tubercular epididymo-orchitis and may avoid unnecessary orchidectomy in a good number of patients.

Keywords
Fine-needle aspiration, granulomatous epididymo-orchitis, tubercular epididymo-orchitis

Introduction and stained with May Grünwald giemsa and haematoxy-

Granulomatous epididymo-orchitis is a term that lin and eosin (H&E), respectively. ZN staining for AFB
encompasses a group of pathologies with different aeti- was also performed in all the cases. Periodic acid Schiff
ology.1 Tuberculosis (TB) is the most common cause in staining (PAS) was carried in AFB-negative cases to rule
low- and middle-income countries.2,3 Involvement of the out a fungal aetiology. FNA findings were correlated
epididymis is fairly common while the testis is rarely with the histopathology wherever available. Following
involved, but the latter is often mistaken as a malig- the cytological diagnosis of granulomatous or tubercular
nancy.4 Fine needle aspiration (FNA) is a minimally epididymo-orchitis, patients underwent clinical workup
invasive diagnostic modality and the aim of our study including erythrocyte sedimentation rate (ESR), chest
was to evaluate the cytomorphology of granulomatous radiography, sputum cytology, Mantoux testing and
epididymo-orchitis. The findings were correlated with abdominal, pelvic and scrotal ultrasonography.
the nature of material aspirated and the status of acid
fast bacilli (AFB) on Ziehl Neelsen (ZN) staining.
Results
Patients were in the age range of 16–70 years. Data are
Patients and methods shown in Table 1. Correlation between material aspi-
Ours was a retrospective study of 40 patients diagnosed rated from and cytologic features of smears in testicular
with granulomatous or tuberculous epididymo-orchitis
on FNA between January 2002 and December 2015. 1
Professor and Head, Department of Pathology, Government Medical
FNA was performed as an outpatient procedure, College and Hospital, Chandigarh, India
whose details were explained to, and informed consent 2
Senior Lecturer, Department of Pathology, Government Medical College
obtained from, the patient beforehand. In a relaxed and Hospital, Chandigarh, India
3
supine position, the patient’s scrotum was prepared Senior Resident, Department of Pathology, Government Medical
with 5% betadine solution, and the suspect swelling or College and Hospital, Chandigarh, India
4
Associate Professor, Department of General Surgery, Government
nodule was fixed between index finger and thumb before Medical College and Hospital, Chandigarh, India
aspirating, using a 23G needle attached to a 10-mL dis-
Corresponding author:
posable syringe mounted on a syringe holder, with the Reetu Kundu, Senior Lecturer, Department of Pathology, Government
other hand. There were no significant complications Medical College and Hospital, Sector 32-A, Chandigarh 160030, India.
noted. Both air-dried and wet-fixed smears were made Email: [email protected]
18 Tropical Doctor 48(1)

or epididymal swellings is shown in Table 2. Epithelioid (PCR) testing was not done owing to cost constraints.
cell granulomas (Figure 1), caseous necrosis (Figure 2), All the patients were started on anti-tubercular therapy
mixed inflammatory cells, Langhans’ giant cells, fibro- (ATT) comprising rifampicin, isoniazid (INH), etham-
blasts, granulation tissue and epididymal cells were seen butol and pyrazinamide in standard doses for two
in varying proportions. Careful search for AFB on months with continuation of rifampicin and INH for
ZN-stained smears showed positivity (Figure 2) in 15 another four months. After initiation of ATT, local and
patients (37.5%). PAS smears searching for fungal constitutional symptomatic relief with a gradual
elements in AFB negative patients were all negative. decrease in scrotal swelling was seen in all but one
Findings of healed pulmonary TB were observed on patient in whom orchidectomy was performed.
chest radiography in four patients. The Mantoux test
was positive in 26 while ESR was raised in 19. Of 16
Discussion
cases with a clinical diagnosis of testicular neoplasm,
biopsy was done in four and an orchidectomy specimen A painless, solid testicular or scrotal lump is generally
was reviewed in one instance. The histopathological considered malignant with only rare exceptions,2
diagnosis in all these cases was granulomatous inflam- which may be grouped under infective and non-infective
mation suggestive of TB. Polymerase chain reaction causes of granulomatous epididymo-orchitis.5–7 Its varied

Table 1. Symptoms and signs of patients with presumptive

clinical diagnosis.

Presumptive Patients
Symptoms and signs clinical diagnosis (n (%))

Painless epididymal and Neoplasm 16 (40)

testicular lump
Epididymal nodule along Tubercular 9 (22.5)
with fever epididymo-orchitis
Tender epididymal Chronic 12 (30)
nodule epididymo-orchitis
Epididymal and testicular Tubercular 2 (5)
enlargement with epididymo-orchitis
inguinal
lymphadenopathy
Epididymal and testicular Chronic 1 (2.5)
nodules with epididymo-orchitis Figure 1. FNA smear showing epithelioid cell granuloma (May
infertility Grünwald giemsa 400).

Table 2. Correlation between material aspirated and cytologic features of smears in testicular/epididymal swellings (n ¼ 40).

Cytological features

Epithelioid cell
Material aspirated; granuloma Epithelioid cell AFB status;
patients (n (%)) Caseation with caseation granuloma patients (n (%)) Aspiration diagnosis

Purulent; 16 (40) 4 12 0 Positive; 12 (75) Tubercular epididymo-orchitis

Negative; 4 (25) Granulomatous inflammation
suggestive of TB
Cheesy/necrotic; 3 (7.5) 0 3 0 Positive; 3 (100) Tubercular epididymo-orchitis
Mixed with blood; 12 (30) 0 2 10 Negative; 2 (16.7) Granulomatous inflammation
suggestive of TB
Negative; 10 (83.3) Granulomatous inflammation
Drop of fluid; 9 (22.5) 0 0 9 Negative; 9 (100) Granulomatous inflammation
Handa et al. 19

seminoma.15 Furthermore, the presence of plentiful

lymphocytes in association with epithelioid cells or
granulomas mandates the exclusion of a seminoma.
TB is a great mimicker of neoplasm. Thus, a histo-
pathological diagnosis of tubercular epididymo-orchitis
in an orchidectomy specimen is no surprise.16 We found
one such case in our study, but almost always repre-
sents an unwarranted and unjustifiable intervention.
The potential risk after FNA of tumour seeding in
the needle track is unproven.15,17,18 To the contrary,
FNA may help by suggesting the correct surgical
approach depending on tumour type.19 FNA offers sev-
eral advantages over a testicular biopsy besides being
cost-effective.18 A biopsy specimen may anyway not be
representative and artefacts may make correct interpret-
Figure 2. Aspirate showing large areas of caseous necrosis in ation problematic. A quick, reliable diagnosis with FNA
tubercular epididymo-orchitis (May Grünwald giemsa 100). in conjunction with ZN staining, however, will usually
Inset shows acid fast bacilli (ZN 1000). produce an early tissue diagnosis and enable prompt
treatment to be instigated. In the case a testicular
aetiology includes TB, brucellosis, syphilis, lepromatous tumour is detected on FNA, immediate surgery with
leprosy, fungal infection, sarcoidosis, malakoplakia and excision of needle track can follow.20
xanthogranulomatous, and idiopathic changes.1 TB is by
far the most common.2 The most common clinical pres-
entation was that of a firm to hard scrotal nodule.8–10 In
Conclusion
60% of cases, a presumptive diagnosis of TB was made TB is the leading cause of chronic granulomatous epi-
on the basis of other associated symptoms or signs but in didymo-orchitis in many parts of the world. It is com-
40% a testicular neoplasm was suspected. One single monly mistaken as a testicular tumour both clinically
patient presented with infertility, an uncommon compli- and radiologically. FNA is a minimally invasive modal-
cation of male genital TB.4 ity which can provide quick diagnosis facilitating med-
Ultrasonographic findings of a testicular tumour and ical treatment. Hence, unnecessary orchidectomy can
granulomatous epididymo-orchitis are very similar, as usually be avoided.
both may show an enlarged heterogeneous testis with
deformation of testicular contour.11 The presence of
epithelioid cell granulomas, Langhans’ giant cells, Declaration of conflicting interests
caseous necrosis and positivity for AFB are diagnostic The author(s) declared no potential conflicts of interest with
features confirming tubercular epididymo-orchitis. respect to the research, authorship, and/or publication of this
We found AFB in patients with purulent or cheesy article.
aspirate, while those with blood mixed or entirely
fluid aspirates were AFB-negative. AFB culture
remains the gold standard for diagnosing TB but Funding
takes six to eight weeks for isolation, by which time a The author(s) received no financial support for the research,
patient is often lost to follow-up. PCR may facilitate authorship, and/or publication of this article.
the diagnosis.12 However, the setup is often still want-
ing owing to cost constraints.
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Tropical Doctor
2018, Vol. 48(1) 20–24
Incidence and risk factors of biliary ! The Author(s) 2017
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fistulation from a hepatic hydatid cyst sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0049475517717177
in clinically asymptomatic patients journals.sagepub.com/home/tdo

Nezih Akkapulu1, H Ozgur Aytac2, Ilker M Arer2, Murat Kus2

and Hakan Yabanoglu2

Abstract
Biliary fistulation from a hepatic hydatid cyst is its most frequent complication. If unrecognised, this may cause difficulties
during and after surgical intervention. Our study looked into its incidence and also the possible risk factors in a retro-
spective investigation of 60 patients (34 women) who had undergone surgery or percutaneous treatment. Demographics
and anatomical characteristics, such as cyst type, location, number, diameter and laboratory findings were examined.
A full 50% had biliary fistulation, with increased risk if the cyst diameter was 8.8 cm.

Keywords
Hepatic, hydatid, echinococcus cyst, biliary fistula
2
MD, Department of General Surgery, Adana Research and Teaching
Centre, Baskent University, Adana, Turkey
Corresponding author:
Nezih Akkapulu, Department of General Surgery, Adana Research and
Teaching Centre, Baskent University, Dadaloglu Mh. 39 Sk. No. 6 Yuregir,
1
MD, FACS, Department of General Surgery, Adana Research and 01250 Adana, Turkey.
Teaching Centre, Baskent University, Adana, Turkey Email: [email protected]