Testicular Coccidioidomycosis

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Testicular Coccidioidomycosis

Wednesday, 30 April 2008

RedOrbit - Dallas,TX*

By Ruggles, Deborah

http://www.redorbit.com/news/health/1363635/testicular_coccidioidomyc

osis/

Coccidioidomycosis (Valley fever) is a systemic fungal infection

endemic to the southwestern United States. Incidence has risen in

the past decade, with more than 100,000 cases diagnosed annually.

This case study discusses a 46-year-old male who presented to the

author's outpatient urology clinic in central California with

painful left scrotal swelling and who was eventually diagnosed with

testicular coccidioidomycosis. While testicular coccidioidomycosis

is not common, the case is presented because consideration as a

differential diagnosis for scrotal masses or lesions in patients who

live in endemic areas is essential. Key Words:

Coccidioidomycosis,Valley fever, epididymitis, male, testicular,

fungal infection.

Coccidioidomycosis, or Valley fever, as it is known in the San

Joaquin Valley of central California, is a fungal infection caused

by arthrospores of Coccidioides immitis. It is the most common

systemic fungal infection in the southwestern United States, seen

particularly in areas that experience mild winters and arid summers,

such as southern California, New Mexico, and Arizona.

Coccidioidomycosis was first recognized as a disease in 1892, and it

was later classified as a fungal infection in 1900.

The prevalence of coccidioidomycosis increased in the 1930s and

1940s as thousands of military personnel settled in the San Joaquin

Valley to build airstrips and participate in desert combat training.

Further, the large influx of immigrants arriving in search of better

farm land also contributed to the increase. More recently, the

incidence of coccidioidomycosis has risen sharply, with

progressively increasing migration to the southwestern United States

and with climate changes in desert regions, bringing extended

periods of drought. The fungus exists in the soil and is released

after disturbance of contaminated soil by humans, dust storms, or

earthquakes. Transmission of the fungus occurs when the airborne

spores are inhaled. The infection is not transmitted from person to

person (Mayo Clinic, 2006; Pappagianis, 1994).

Case Presentation

A 46-year-old Hispanic male was referred to the Urology Clinic at

Veteran's Administration Central California Healthcare System

(VACCHCS) for acute epididymitis. Initially, the patient's left

epididymis was enlarged three to four times its normal size, and the

scrotal area was firm and exquisitely tender. His past medical

history was significant for Hepatitis C, post-traumatic stress

disorder, and poly-substance abuse, but he denied any recent drug or

alcohol use. He was unaware of any previous cocci infection.

Clinical Interaction

Ciprofloxacin 500 mg orally twice daily and hydrocodone 10 mg one to

two tablets every four to six hours as needed for pain were

prescribed, and the patient was advised to wear an athletic

supporter. An ultrasound of the scrotum was ordered. Laboratory

tests included a complete blood count (CBC), electrolytes,

urinalysis, and urine culture and sensitivity. The patient was

instructed to return to the clinic within four weeks or sooner if

his symptoms worsened.

Results of Clinical Interaction

Initial laboratory results showed the CBC within normal limits, with

the exception of a low platelet count of 99,000 (150,000 to 400,000

mm3). His electrolytes, urinalysis, and urine culture were all

within normal limits. The initial ultrasound revealed a well-

circumscribed, echogenic mass in the lower pole of the left

testicle, suggesting a focal area of orchitis. Differential

diagnosis included atypical infection or possible infectious

neoplasm.

After a month of conservative treatment, the patient returned with

only mild improvement of his symptoms. On physical examination, most

of his hemiscrotal swelling had resolved. The intratesticular mass

seen on ultrasound could not be palpated, but the epididymis

remained enlarged and exquisitely tender. Ciprofloxacin was

increased to 750 mg. twice daily, and a repeat testicular ultrasound

and tumor markers were obtained.

The repeat ultrasound demonstrated approximately 1 cm. foci of

hypoechogenicity in the left testicle, and the left epididymis was

engorged and demonstrated increased flow by Doppler, consistent with

epididymitis. Serum alphafetoprotein was 58.2 ng/ml (0 to 8), LDH

was 280 IU/L (91 to 180), and quantitative F-HCG was < 5 (0 to 5).

The patient was taken to surgery and underwent a left inguinal

orchiectomy. The lower pole testicular mass revealed purulent

drainage, and the culture showed a moderate growth of fungus. The

final culture proved to be Coccidioides immitis. Fluconazole 400 mg

orally once daily for 14 days was prescribed. The patient recovered

without any additional problems and remained symptom free for six

months postoperatively. He was referred to the Infectious Disease

Clinic for ongoing follow up and management.

Clinical Implications

It is estimated that more than 100,000 new cases of Coccidioides

immitis are diagnosed each year in the United States (Chiller,

Galgiani, & s, 2003; Mayo Clinic, 2006). In endemic areas, up

to 80% of the population has a positive coccidioidin skin test,

demonstrating previous exposure. Risk groups include those living in

endemic areas whose occupations expose them to dust (such as

construction workers and agricultural workers). High-risk groups

include individuals who are immunocompromised, African Americans,

Asians, and women in the third trimester of pregnancy. Clinical

manifestations may include asymptomatic infection; flu-like illness

with fever, cough, headache, rash, or myalgias; or fulminant

pneumonia. Generally, about 60% of cases will present with a

subclinical picture, and the remainder will have a mild to severe

respiratory illness. Most patients will have complete resolution of

symptoms, although approximately 5% will have some pulmonary

residual effects. Extrapulmonary dissemination of the infection

occurs in less that 1% of those affected. Dissemination usually

occurs several months after the primary infection. It usually is

highly fatal, and meningeal involvement is often the cause of death

(Dykes, Stone, & Canby- Hagino, 2005; Singer, 2002).

Coccicioidomycosis of the genitourinary system implies active or

previous dissemination of the fungus. Pulmonary and meningial

lesions dominate the clinical picture, but dissemination to the

genitourinary tract is not rare (Wise, 2001). Genitourinary

dissemination is generally only found on post-mortem examination.

Autopsies reveal 35% to 60% of patients who die from disseminated

Coccidioides immitis have renal involvement. Involvement of other

genitourinary tract organs is much less common, with about 6%

prostate involvement and less than 2% testicular involvement

(Conner, Drach, & Bucher, 1975; Singer, 2002; Wise, Talluri, &

Marella, 1999).

Coccidioidomycosis presenting as a testicular mass has been rare. In

a case discussed by Liao and Reiter (2001), the patient was a

lifelong resident of the San Joaquin Valley and initially presented

with a painless scrotal mass. A case reviewed by Dykes et al. (2005)

involved a painless, firm right scrotal mass found on routine

physical examination of a 78-yearold patient. Both required surgical

intervention (orchiectomy) and systemic antifungal therapy.

Conclusion

Infection in the male reproductive system caused by Coccidioides

immitis is rare and may evade diagnosis, delaying appropriate

treatment (Halsey & Rasnake, 2005, Wise et al., 1999). Cocci found

in the genitourinary tract post-mortem are relatively common;

however, in the absence of systemic illness, antemortem

genitourinary cocci is infrequent but should be considered as part

of the differential diagnosis in patients with epididymitis,

epididymo-orchitis, or prostatitis and who reside in endemic areas

(Sohail, s, & Blair, 2005).

It is estimated that more than 100,000 new cases of Coccidioides

immitis are diagnosed each year in the United States.

References

Chiller, T.M., Galgiani, J.N., & s, D.A. (2003).

Coccidioidomycosis. Infectious Disease Clinics of North America, 17,

41-57.

Conner, W., Drach, G., & Bucher, W. (1975). Genitourinary aspects of

disseminated coccidioidomycosis. Journal of Urology, 113(1), 82- 88.

Dykes, T., Stone, A., & Canby-Hagino, E. (2005). Coccidioidomycosis

of the epididymis and testis. American Journal of Roentgenology,

184, 552- 553.

Liao, J.C., & Reiter, R.E. (2001). Coccidioidomycosis presenting as

a testicular mass. Journal of Urology, 166(4), 1396.

Halsey, E., & Rasnake, M. (2005). Coccidioidomycosis of the male

reproductive tract. Mycopathologia, 159(2), 199-204.

Mayo Clinic. (2006). Valley fever. Retrieved September 3, 2007, from

http://www.mayoclinic.com/health/ valley-fever/DS00695

Pappagianis, D. (1994). Marked increase of coccidioidomycosis in

California 1991, 1992, 1993. Clinical Infectious Disease, 19(Suppl.

1), 14-18.

Singer, A. (2002). Coccidioidomycosis of the epididymis and

testicle. Infectious Urology, 15(2), 21-25.

Sohail, M.R., s, P.E., & Blair, J.E. (2005).

Coccidioidomycosis of the male genital tract. Journal of Urology, 173

(6), 1978-1982.

Wise, G.J. (2001). Genitourinary fungal infections: A therapeutic

conundrum, Expert Opinion on Pharmocotherapy, 2(8), 1211-1226.

Wise, G.J., Talluri, G.S., & Marella, V.K. (1999). Fungal infections

of the genitourinary system; Manifestations, diagnosis, and

treatment. Urology Clinics of North America, 26(4), 701- 718.

Deborah Ruggles, MS, NP-C, is a Nurse Practitioner, Urology

Department, Veterans Administration Central California Healthcare

System, Fresno, CA.

Copyright J. Jannetti, Inc. Apr 2008