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A single-center study from Wuhan in China presents evidence from ultrasound imaging supporting the idea that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause an infection of the testicle or epididymis and put patients at risk of further complications. The document can be found in the Journal of Ultrasound in Medicine.
Colored scanning electron micrograph of an apoptotic cell (green) heavily infected with SARS-CoV-2 virus particles (purple), isolated from a patient sample. Image captured at the NIAID Integrated Research Facility (IRF) at Fort Detrick, Maryland. 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) that recognizes a specific cell surface receptor . In humans, angiotensin converting enzyme 2 (ACE2) has been identified as the major functional receptor for SARS-CoV and SARS-CoV-2 RBD.
The ACE2 expression pattern implies that SARS-CoV-2 could affect the function of multiple organs in the human body. More specifically, some previous and recent studies on coronavirus have shown that this virus can affect many organs beyond the lungs, such as the kidneys, digestive tract, brain, liver, heart, thyroid gland, and testicles.
When it comes to human testicular tissue, ACE2 is essentially expressed in undifferentiated male germ cells (spermatogonia), Setoli cells, and Leydig cells. Therefore, if we assume the receptor interaction with respect to the ACE2 distribution, there is reason to believe that SARS-CoV-2 can attack both the testis and the epididymis.
In a recent study, a research group from China (led by Dr. Liao Chen of the Department of Ultrasound Imaging at Renmin Hospital of Wuhan University) acquired direct ultrasound imaging findings of acute scrotal infection in hospitalized patients with COVID- 19 during the pandemic.
A retrospective study of hospitalized patients with COVID-19
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 underwent a bedside scrotal ultrasound with a delay of 1 week to 1 month after the initial symptoms of the disease.
Scrotal ultrasound studies focused on imaging manifestations related to acute orchitis, epididymitis, and epididymo-orchitis, with the subsequent use of specific diagnostic criteria. Furthermore, the proportion of epididymorchitis observed in patients belonging to different age groups and COVID-19 severity was compared.
The ultrasound images of each case were read by two sonographers; in cases where their impressions disagreed, the final verdict was delivered by a senior professor specializing in imaging diseases of the male urogenital / reproductive system and with over twenty years of professional experience.
Main findings of ultrasound
Of a total of 142 COVID-19 patients enrolled in this study, 39 of them (27.5%) showed inflammatory imaging signs such as a thickened fibrous covering of the testicles (tunica albuginea), increased blood flow in the blood vessels Swelling, scrotal tissue enlargement due to hydrocele or abscesses.
Furthermore, a total of 32 patients (22.5%) had a diagnosis of acute inflammation of one or both testicles, epididymitis, or both (epididymorchitis) 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 found that men with severe COVID-19 had a substantially higher chance of developing epididymo-orchitis compared to the COVID-19 group without severe disease. All of this means that the testes are indeed a potential target for SARS-CoV-2.
However, it should be noted that many COVID-19 patients are in a state of lowered immunity, allowing bacteria from the ascending urinary tract to develop and cause scrotal infections. Furthermore, hormonal dysregulation is also present and can aggravate this problem.
Implications for clinical practice
In short, the results of this study support the idea that SARS – CoV – 2 infection can specifically affect the testicle, the epididymis, or both. Of course, the systemic inflammatory reaction and present comorbidities must be taken into account because they can also result in tissue enlargement and testicular inflammation.
“We suggest that clinicians be aware of the risk of acute scrotal infection in hospitalized COVID-19 patients, and in young male COVID-19 patients (especially those who wish to have children), local symptoms and fertility should be monitored and carefully protected, “warn the study authors.
In any case, more research efforts should be made based on biopsies or autopsies to determine if the pathological and histological changes caused by SARS – CoV – 2 can be found in the testes and epididymis of patients with COVID – 19.
