Case Report

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! The Author(s) 2018
Scrotal abscess consequent Article reuse guidelines:
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on syphilitic epididymo-orchitis DOI: 10.1177/0049475518809240
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Vivek Agrawal1 and Rohit Ranjan2

Abstract
Syphilis is notorious and a great imitator of all diseases. It is a chronic bacterial infection, caused by the sexually
transmitted spirochete, Treponema pallidum. Though it has drastically reduced in prevalence, its recent resurgence
(especially with HIV disease) is worrying. Without treatment, the disease can progress over years through a series of
clinical stages and lead to irreversible neurological or cardiovascular complications. The disease may occur in any organ,
including the testis, and is commonly mistaken for malignancy. We report a case of scrotal abscess consequent on
epididymo-orchitis, confirmed by histopathological examination to be syphilitic in origin, in an immunocompromised
HIV-positive patient.

Keywords
Syphilis, sexually transmitted disease, AIDS, syphilitic epididymo-orchitis, scrotal abscess, testicular lesion

seen to have destroyed the testicular parenchyma

Case report
A 40-year-old man presented with complaints of pain
and swelling over the left half of his scrotum apparently
for 10 days. This had started to discharge over the pre-
vious two days. He had had multiple sexual partners and
was already on anti-retroviral treatment for the past
year. There was no history of fever, urinary symptoms
or previous genital lesion in the past. There was swelling
of the left half of the scrotum with a 2-cm-sized abscess
discharging pus from its infero-lateral aspect. The right
hemi-scrotum and the penis were normal. No inguinal
lymphadenopathy was noted. Blood parameters were
within normal limits. Incision and drainage of the
abscess was performed; after some pus was evacuated,
yellowish cheesy material was found adherent to the
testis and originating therefrom. After debridement, a
punched-out ulcer with an indurated base was found
on the anterior surface of an enlarged left testis
(Figure 1). A left orchidectomy was carried out and
the wound left open to heal by secondary intention.
The patient subsequently showed marked clinical
improvement on broad spectrum antibiotics (Inj.
Ceftriaxone and Metrogyl), following which a single
dose of inj. Benzathine benzylpenicillin (2.4 million
units) was given.
On histological examination, intense inflammation
with a dense plasmocytic infiltrate along with other
inflammatory cells and haemorrhagic necrosis was
(Figure 2). The seminiferous tubules showed extensive
atrophic changes. The epididymis was relatively spared
of inflammation. These features are consistent with
syphilitic orchitis. In addition, coliforms were grown
from the abscess cavities.
Discussion
Syphilis, caused by the sexually transmitted spirochete,
Treponema pallidum,1 used to be known as the great
imitator of all diseases, though this position has now
been overtaken by HIV disease.2 However, syphilis is
on the rise globally, especially among men who have
sex with men,3,4 and its diagnosis can no longer be
relegated to the history books. It is a multi-system
and multi-stage disease, which can affect any organ,
classically the testis causing asymptomatic progressive
painless swelling which can mimic malignancy.1,2
Syphilis classically passes through stages: (1) the
1
Director Professor, Department of Surgery, UCMS and GTB Hospital,
New Delhi, India
2
Junior Resident, Department of Surgery, UCMS and GTB Hospital, New
Delhi, India
Corresponding author:
Rohit Ranjan, Department of Surgery, UCMS and GTB Hospital, New
Delhi, India.
Email: dr.rohitranjan@gmail.com
2 Tropical Doctor 0(0)
Figure 1. Gross specimen of testis- showing punched out
lesion.
Figure 2. Histopathology of testis- showing parenchymal
destruction.
penile chancre; (2) a rash; (3) the gumma; and (4) (much
later) tabes dorsalis and general paralysis.5
As syphilis and HIV are transmitted sexually, their
co-existence is readily explained.2,6 Furthermore, the
open ulceration caused by the syphilitic gumma may
pre-dispose to HIV infection, through haematogenous
contact.6 In addition, immunosuppression from HIV
disease allows more rapid progression through the
‘stages’ of syphilitic disease, so that the first and
second stages (namely, the chancre and the rash) may
not be observed at all.6
While the syphilitic testicular gumma classically pre-
sents as the ‘billiard-ball testis’ (i.e. one that is solidly
hard and round), ulceration can occur, as in our case,
possibly as the result of secondary infection. Normally
scrotal ulceration from granulomatous disease would
clinically imply tuberculous epididymo-orchitis (which
normally spares the testis itself), while syphilis is usually
found primarily within the testis.5 Thus, our case is one
that defies this rule!
Intramuscular benzathine benzylpenicillin G (BPG)
has for years been the drug of choice (enabling single-
dose usage),7 but its antibiotic concentration build-up is
slow and it fails to cross the blood–brain barrier and so
cannot treat neurosyphilis.4 In addition, the Jarisch-
Herxheimer reaction, which occurs more commonly
where syphilis is co-existent with HIV, occurs more fre-
quently with penicillin treatment than macrolides.8
However, substantial resistance to macrolides has
developed and is well documented,3,6 so their use is
not recommended unless local sensitivities are known.
Nonetheless, doxycycline and ceftriaxone have been
found to be effective alternatives.7,9 Whether BPG is
still the drug of choice for syphilis in HIV patients is
uncertain.7
No vaccine is yet available for syphilis;10 thus, con-
trol of this disease depends on sexual partner tracing.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Rohit Ranjan http://orcid.org/0000-0003-3035-3766
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