Ultrasound reveals a attainable position for SARS-CoV-2 in acute testicular infections

A single-center study from Wuhan, China provides evidence of ultrasound imaging to support the belief that severe coronavirus 2 (SARS-CoV-2) with acute respiratory syndrome can cause an infection of the testicle or epididymis – and the risk for further complications in patients increased. The paper can be found in the Journal of Ultrasound in Medicine.

Colored scanning electron microscope image of an apoptotic cell (green) that is heavily infected with SARS-CoV-2 virus particles (purple) and that was isolated from a patient sample. The image was taken at the NIAID Integrated Research Facility (IRF) in Fort Detrick, Maryland. Image Credit: NIAID

Previous studies have already shown that SARS-CoV-2, a causative agent of coronavirus disease (COVID-19), enters a host cell using its receptor binding domain (RBD), which recognizes a specific cell surface receptor. In humans, the angiotensin converting enzyme 2 (ACE2) has been identified as the most important functional receptor for the RBD of SARS-CoV and SARS-CoV-2.

The expression pattern of ACE2 implies that SARS-CoV-2 could affect the function of several organs in the human body. In particular, some previous and recent studies on coronavirus have shown that this virus can actually affect many organs outside of the lungs, such as the kidneys, digestive tract, brain, liver, heart, thyroid, and testes.

When it comes to human testicular tissue, ACE2 is mainly expressed in undifferentiated male germ cells (spermatogony), Setoli cells and Leydig cells. So if we assume a receptor interaction regarding the distribution of ACE2, there are reasons to believe that SARS-CoV-2 can attack both the testes and the epididymis.

In a recent study, a research group from China (led by Dr. Liao Chen from the Ultrasound Imaging Department of Renmin Hospital, Wuhan University) obtained direct ultrasound imaging of acute scrotal infection in patients who insured with COVID-19 during the pandemic Hospitalized.

A retrospective study of hospitalized COVID-19 patients

This retrospective study included male patients with a confirmed diagnosis of COVID-19 during their hospitalization in the early days of the pandemic, who also had bedside scrotum ultrasound performed with a delay of 1 week to 1 month after the first symptoms of the pandemic Illness.

Ultrasound exams of the scrotum focused on the imaging manifestations associated with acute orchitis, epididymitis, and epididymo-orchitis, followed by specific diagnostic criteria. In addition, the proportion of observed epididymo-orchitis in patients of different ages and COVID-19 severity was compared.

The ultrasound images for each case were read by two ultrasound specialists; In cases where their impressions did not match, the final judgment was made by a senior professor who specializes in the imaging diagnosis of diseases of the male genitourinary / reproductive system and has more than twenty years of professional experience.

Important results of ultrasound imaging

Of a total of 142 patients with COVID-19 who participated in this study, 39 (27.5%) showed inflammatory imaging features such as a thickened fibrous covering of the testicle (tunica albuginea), increased blood flow to the tissue enlargement of the blood vessels, scrotal swelling due to hydrocele or Abscesses.

In addition, a diagnosis of acute inflammation of one or both testicles, epididymitis or both (epididymis) was made in a total of 32 patients (22.5%) according to the diagnostic criteria. The observed risk of acute scrotal infection also increased with age, reaching 53.3% in patients older than 80 years.

The researchers also observed that men with severe COVID-19 were significantly more likely to develop epididymo-orchitis compared to the COVID-19 group without severe illness. All of this means that the testes are actually a potential target for SARS-CoV-2.

It must be noted, however, that many patients with COVID-19 are in a state of decreased immunity, which allows bacteria to break out from the ascending urinary tract and cause scrotal infections. In addition, there is also hormonal dysregulation that can make this problem worse.

Implications for Clinical Practice

In short, the results of this study support the belief that SARS-CoV-2 infection can specifically affect the testes, epididymis, or both. Of course, systemic inflammatory responses and current comorbidities must be taken into account, as they can also lead to tissue enlargement and testicular swelling.

"We recommend clinicians remain aware of the risk of acute scrotal infection in hospitalized patients with COVID-19. In young male patients with COVID-19 (especially children planning to have children), local symptoms and fertility should be carefully monitored and monitored be protected, "caution study authors.

In any case, further research based on a biopsy or autopsy should be conducted to determine whether pathological and histological changes caused by SARS-CoV-2 can be found in the testes and epididymis of patients with COVID-19.

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