Background Epididymitis has several etiologies that can be related to infectious and non-infectious causes, autoimmune conditions, aseptic causes, and even certain pharmaceutical medications (amiodarone and chemotherapeutic agents). Some cases of epididymitis are complicated with pyocele formation that requires emergent surgical intervention to prevent testicular gangrene. This report describes the case of a 66-year-old male who developed severe bilateral epididymitis complicated by bilateral pyocele and ensuing sepsis. Astonishingly, the condition resolved completely without surgical intervention. Case presentation We are presenting a case of a non-sexually active male who developed bilateral severe epididymitis complicated by pyocele that led to the development of septic shock. Further history revealed that the patient was not sexually active with male or female partners and denied any form of trauma. Physical examination demonstrated scrotal swelling and erythema on inspection and severe tenderness on palpation. Digital rectal examination as well as abdominal examinations was unremarkable. Laboratory investigations disclosed severe leukocytosis with a neutrophil predominance (39,000 K/UL, normal range 4500–11,000 K/UL), as well as an elevation of systemic inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein. Urine culture was positive for Escherichia coli. Ultrasound revealed bilateral epididymitis and pyocele. This patient was managed with a course of meropenem, resolving the epididymitis and pyocele without the need of surgical intervention. Conclusions Surgical intervention is considered the standard of care and the approved management for pyocele to avoid further complications such as Fournier’s gangrene. However, this patient was treated solely with antibiotics, and his condition was stabilized without the need of surgical intervention that would result in additional cost and length of stay for the patient. This case raises further questions regarding the potentially better bioavailability of this antibiotic in the scrotum compared to elsewhere in the body and the potential for a non-surgical alternative approach in the management of patients with pyocele and requires further research.
Japanese encephalitis virus is an RNA flavivirus and one of the rare pathogens that can cause encephalitis. The main vector is the Culex tritaeniorhynchus mosquito. The virus is very close in pathophysiology and structure to the West Nile and St. Louis encephalitis viruses. It is endemic in Asia and Western Pacific areas, mostly during the summer; only a few cases have been reported outside those regions. We present the case of a young Filipino cruise line male worker with signs and symptoms of Japanese encephalitis concomitantly with Miller Fisher syndrome and Bickerstaff brainstem encephalitis. The patient developed obtundation, ataxia, areflexia, flaccid paralysis, and ophthalmoplegia, which were preceded by a few days of constitutional symptoms (fever, malaise, fatigue and anorexia). Physical examination showed various stages of erythema nodosum on the lower extremities. Analysis of cerebrospinal fluid was positive for anti-GQ1b, West Nile IgG and Japanese encephalitis IgM. Despite the neurological complications and bradyarrhythmia occurring during hospitalization, the patient recovered completely under our regimen.
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