Visceral candidiasis is uncommon in patients with type 2 diabetes (1). Here, we discuss the sixth known case report of fungal epididymitis in a diabetic patient and only the second one caused by Candida glabrata. Two cases of epididymitis caused by C. glabrata have been described in nondiabetic patients, one in an HIV-positive individual (2), and the other in a permanently catheterized patient (3).
An 81-year-old male type 2 diabetic patient who was on a twice-daily insulin regimen was admitted for intermittent fever and confusion over the previous 2 days. Past history revealed a stroke 2 years earlier that led to permanent urinary catheterization, along with several short courses of oral antibiotics. No information about his previous diabetes control was available. Physical examination showed fever (37.8°C), tachycardia of 100 beats per min, and a warm, enlarged, erythematous, indurated, and tender left hemiscroteum. Laboratory tests showed normochromic and normocytic anemia (hematocrit 31.7%), leukocytosis (17,800/μl), hyperglycemia (363 mg/dl), and hypercreatinemia (1.9 mg/dl). Scrotal ultrasound revealed a solid, heterogenous mass with increased vascularization over the left testis, whereas the right testis was normal. Budding yeast forms were recognized on urine microscopy, and urine culture yielded 5 × 105 CFU/cm3 of C. glabrata.
The patient was started on a fluconazole 200-mg i.v. b.i.d., and, due to persistence of clinical symptoms, 3 days later he underwent a left epididymo-orchiectomy, abscess drainage, and surgical excision of tunica vaginalis and of the overlying skin and dartos muscle. Histology showed cavitary abscess and acute inflammation in the epididymis that extended to the overlying skin layers without involving the testis. Numerous pseudohyphae were present on the wall of the abscess staining that were positive for p-aminosalicylic acid (PAS).
Culture of the pus on Saboureau’s medium yielded C. glabrata. Identification and sensitivity testing of antifungals were performed as described elsewhere (3). C. glabrata was of intermediate susceptibility to fluconazole and susceptible to other antifungals. After surgical excision, the patient was continued on the intravenous regimen for 7 days. When discharged, the patient was placed on an oral fluconazole 200-mg b.i.d. for 10 additional days. Three months later, the patient remained without any relapse.
A Medline search from 1966 to 2000 revealed five cases of fungal epididymitis connected to type 2 diabetes (5,6,7,8,9) that shared several common characteristics with the present case. Permanent catheterization and former antibiotic consumption are the main predisposing factors. Infection occuring by C. albicans or C. glabrata and involving one or both epididymes may or may not be accompanied by involvement of the testis and by abscess formation. Diagnosis is based on the recognition of fungi, either in histology, in cultures of the draining pus, or in both. Because urine cultures always yield the fungi, this indicates retrograde spread as the responsible mechanism that involves the epididymes. Treatment consists of surgical drainage accompanied by the administration of antifungal agents, mainly fluconazole for 10–30 days, even if the isolated species is of intermediate susceptibility to fluconazole, as in the present case report.
In conclusion, although this occurance is rare, any diabetic patient with inflammation of the scrotum and former consumption of antibiotics should bear in mind the possibility of developing fungal epididymitis.
References
Address correspondence to N. Katsilambros, MD, PhD, Professor of Internal Medicine, Medical Director, First Department of Propaedeutic Medicine, 5 Doryleou St., GR 115 21 Athens, Greece. E-mail: [email protected].
