Teaching Case

A 30-year-old male patient complained about hypogastrium and bilateral testicular pain, mainly in the right testicle and 37.9 ºC quantified fever.

He was a smoker of 2-3 cigarettes a day and a consumer of marijuana and cocaine in the past. There were no other medical records of interest.

Several scrotal ultrasound examinations were performed to this patient.

The first ultrasound examination was performed on 02/09/19 and highlighted the presence of bilateral multiple testicular lesions, more remarkable in the right testicle (Figure 1, Figure 2).

The second ultrasound was performed ten days later (12/09/19) in order to evaluate the evolution of the lesions after conservative treatment with antibiotics (right testicle is shown in Figure 3 and Figure 4; left testicle is shown in Figure 5).

The last examination was made on 07/10/19 when the patient returned to the hospital with left testicular pain. The images were taken some week after radical right orchiectomy (Figure 6).

The anatomopathological analysis of the right testicle highlighted the diagnosis of testicular vasculitis.

Vasculitis is an inflammatory process of the blood vessels wall with antineutrophil cytoplasmic antibodies (ANCA) participation [1]. The most common systemic vasculitis causing testicular involvement is polyarteritis nodosa, almost 70% in necropsies series [2]. Single-organ testicular vasculitis, with small and medium-sized blood vessels damage, can sometimes be the presentation, like our case. The most common finding in this presentation is the unilateral testicle involvement, followed by epididymal and spermatic cord damage in third place [3]. Patients are usually younger than 50 years [4]. The common clinical presentation is testicular pain and inflammation without any alteration of analytics parameters.

The most common ultrasound presentation is an avascular heterogeneous hypoechoic mass or masses, as our case (Figure 7, Figure 8). This presentation has been related to both hematoma and acute vasculitis with thrombosis [5,6] whose consequence is the formation of areas of testicular infarction with haemorrhagic necrosis [7], as showed the second ultrasound (Figure 9, Figure 10, Figure 11). In our case, multiple abscesses were the first diagnosis of suspicion. Eventually, the quick worsening of the right teste lesions between the 1^st and 2^nd examination after antibiotics raised an aggressive neoplasm as a possible diagnosis and the right teste was removed. Most of these patients are definitely diagnosed after a radical orchiectomy because of tumoral suspicion [3].

Macroscopically, the removed testicle had external punctiform hemorrhagic lesions (Figure 12) and an internal hemorrhagic area (Figure 13). The anatomopathological analysis revealed typical vasculitis findings: fibrinoid necrosis and inflammatory cells infiltration of the blood vessel wall (Figure 14), with large areas of hemorrhagic necrosis in the testicular parenchyma (Figure 15) [8].

Given the diagnostic difficulties, most testicular vasculitis are surgically treated, but there is possible a conservative treatment with immunosuppressive therapy [9]. Theoretically, the resection of a damaged organ in a single-organ vasculitis would be curative, although single-organ vasculitis could be the first clinical manifestation of a systemic vasculitis [6].

The prognosis depends on developing a systemic vasculitis process and on the evolution of the lesions. Nowadays, our patient hasn’t any analytical sign of systemic vasculitis and the lesions of the left testicle have remarkably improved after corticosteroid therapy (Figure 16).

Teaching point:  Testicular vasculitis is part of the differential diagnosis facing a patient with testicular pain and inflammation and avascular hypoechoic lesions on ultrasound exam.