Nodularity at the base of left side scrotum. The patient had a similar episode 1 year ago for which an excision biopsy was performed showing Chronic granulomatous infection, likely Koch's.
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Enlarged heterogenous appearance of epididymis mainly in the region of tail with increased vascularity. The lesion is predominantly hyperechoic with increased vacularity. The picture was confusing with funiculitis, however thickening of spermatic cord is present at the superior aspect of testis while this was at the base.
Biopsy was done which showed chronic granulomatous infection most likely Tuberculous in etiology.
Tuberculous epididymitis generally occurs in the tail of epididymis as it is most vascular and its relation with the vas deferens to be involved with urinary reflux. USG generally shows diffuse heterogenous predominantly hypoechoic enlarged epididymis or focal nodular hypoechoic lesion within it. Preferentially the tail is involved while the head is spared. The heterogeneity could be due to caseating necrosis, granulomas and fibrosis. A heterogenous, enlarged epididymis favours tuberculous involvement than non tuberculous involvement as it may show homogenous echotexture of enlarged epididymis. Increased colour flow differentiate this condition from infarction. However, tumour can still be a possibility.
The variation in this case was the echogenicity. As it was hyperechoic rather than being hypoechoic as seen in usual cases. As patient had also done excision biopsy 1 year back of similar nodule in this region, we attribute it to post procedure changes. However it should be further studied in detail.
- M Muttarak, c g Wilfred et al., Tuberculous epididymitis and Epididymo-orchitis: Sonographic appearance, Pictorial Assay; AJR 2001; 176:1459-1466.