Testicular sarcoidosis

Clinical History

A 27-year-old male presented with multiple painless swellings in both testes and normal testicular tumour markers.

Imaging Findings

A 27-year-old male patient presented with painless swellings in both testes. On examination, both testes were found to be of normal size with numerous ‘shotty’ lumps over the globe of both testes. Testicular tumour markers were also found to be normal. A scrotal ultrasound was performed, which revealed the presence of multiple, bilateral hypoechoic lesions within both testes (Fig. 1). A likely diagnosis of lymphoma or acute lymphoblastic leukaemia was postulated and a right testicular biopsy was performed. Histological analysis revealed the presence of multiple non-caseating granulomas. Multinucleate giant cells were present with a sparse lymphocytic infiltrate. No spermatogenesis was identified. The findings were typical of testicular sarcoidosis. A chest X-ray was taken, which revealed no evidence of pulmonary sarcoidosis. The patient was treated with oral steroids after subsequently developing neurosarcoidosis of the trigeminal nerve. A repeat testicular ultrasound scan taken four months later showed a decrease in the size of the multiple, bilateral hypoechoic lesions, indicating a response to steroid therapy.

Discussion

Sarcoidosis is an idiopathic granulomatous disease that may affect any organ system. It is the most frequently occurring interstitial lung disease. It is 20 times more common in black patients than in white patients and the female-to-male ratio is 10:1. Pulmonary sarcoidosis accounts in 84% of cases, whereas urogenital involvement occurs in 0.2% of the cases (where it usually involves the kidney). Testicular sarcoidosis is rare, especially as a presenting feature of the disease without any evidence of pulmonary involvement. The presentation may range from an asymptomatic painless testicular mass to an acute painful swelling. Ultrasound remains the imaging of choice in testicular sarcoidosis: hypoechogenicity is the hallmark (1, 2). Both sarcoidosis and testicular tumours have their peak incidence in the third decade of life; it is clinically difficult to exclude malignancy even in the presence of pulmonary sarcoidosis. There may also be an association between sarcoid-like lesions and testicular malignancy even in the presence of pulmonary sarcoidosis. There may also be an association between sarcoid-like lesions and testicular malignancy (3). As a result of this, many authors have advocated the use of orchidectomy in suspected cases of testicular sarcoidosis (4, 5), especially in patients with unilateral testicular involvement and in those where fertility is not an issue. In cases where testicular sarcoidosis has been diagnosed but where orchidectomy has not been performed, a follow-up with repeat ultrasound scanning is a reasonable approach. The diagnosis of testicular sarcoidosis should be considered in the differential diagnosis of testicular masses; however, care must be taken to exclude malignancy even when there is a known history of sarcoidosis.

Differential Diagnosis List

Final Diagnosis

Testicular sarcoidosis.

URL:	https://www.eurorad.org/case/3222
DOI:	10.1594/EURORAD/CASE.3222
ISSN:	1563-4086