EPIDIDYMITIS AND PROSTATITIS DUE TO COCCIDIOIDOMYCOSIS: A CASE REPORT WITH 5-YEAR FOLLOWUP

COCCIDIOIDOMYCOSIS OF THE MALE GENITAL TRACT

PURPOSE

Symptomatic genital tract infection is a rare manifestation of disseminated coccidioidomycosis. We characterized the clinical presentation, diagnosis, management and outcome in male patients with genitourinary coccidioidomycosis.

MATERIALS AND METHODS

We reviewed all cases of genital tract coccidioidomycosis involving testes, epididymis or prostate at our institution between 1990 and 2000, and searched the medical literature for all reports since the first reported case in 1943.

RESULTS

A total of 30 male patients with a median age of 58 years who had coccidioidomycosis of the genital tract were identified, including 6 at our institution. Four patients (13%) had a simultaneous pulmonary infection and 63% (19) had a remote history of primary pulmonary coccidioidomycosis. The most commonly involved genital tract sites were the epididymis in 18 cases, prostate in 14 and testes in 6. Patients with prostatitis presented with urinary obstruction, prostatic enlargement, tenderness and palpable nodules. Most patients with epididymal infection presented with scrotal swelling, tenderness and induration. All 30 patients (100%) had histopathological evidence of granulomatous inflammation with fungal spherules. Urine fungal cultures were positive in 19 cases (63%). A total of 12 patients received combined medical and surgical treatment, and 18 underwent surgical excision only. Most immunocompetent patients with isolated genital coccidioidomycosis did well with surgical resection alone. Six deaths occurred in patients with multifocal, extragenital, disseminated disease.

CONCLUSIONS

Male genitourinary coccidioidomycosis is rare but it should be considered in the differential diagnosis of patients with exposure to the endemic area who present with prostatitis or epididymitis.

Coccidioidomycosis of the male reproductive tract

Coccidioides immitis infection of the male reproductive tract is a rare entity that can evade diagnosis and pose a dilemma in management. Initially, patients are often evaluated for malignancy or other infections such as tuberculosis. In the past, surgery was the only management option for C. immitis infection of the male reproductive tract, but azole therapy now provides an adjunct or an alternative. We describe two patients who received azole therapy for C. immitis infection of the male reproductive tract. One received fluconazole for prostatic disease, while one received surgery followed by itraconazole for testicular disease. After 12 months of therapy, both remain asymptomatic and have decreased antibody titers against C. immitis.

Genitourinary coccidioidomycosis

Symptomatic involvement of the genitourinary tract as a manifestation of disseminated Coccidioides immitis infection is uncommon. We report a case of a colovesical fistula secondary to Coccidioides immitis infection and review the pertinent medical literature.

Coccidioidomycosis of the epididymis

A rare case of coccidioidomycosis involving the epididymis is described and compared with the 12 clinically diagnosed cases reported in the literature. With 1 exception, the disease appeared to be limited to the genital organs and the adjacent tissue. Surgical excision of the involved tissue appeared to be curative. Bilateral epididymal involvement occurred in 4 cases and it was the cause of the treatment failure in 2 of the 3 cases in which the local disease was treated unsuccessfully by surgery. The efficacy of antifungal chemotherapy remains to be determined.

Genitourinary aspects of disseminated coccidioidomycosis

Genitourinary involvement is common in disseminated coccidioidomycosis. Urologic evaluation should include careful examination, cultures and radiograms. The radiographic features of renal coccidioidomycosis parallel those of renal tuberculosis, with feathery, moth-eaten calices, infundibular constriction and caliceal ballooning, and eventual calcification of granulomas. Coccidioidal epididymitis may be chronic, with long asymptomatic intervals. A patient with a 15-year interval between episodes of right and left coccidioidal epipidymitis is described. Complement fixation titers should be used to determine the activity of genitourinary coccidioidomycosis. In 3 of 12 patients dissemination of coccidioidomycosis occurred during treatment with immunosuppressive medications. Renal transplant patients should be evaluated for active coccidioidomycosis prior to transplantation.