Testicular vasculitis

Case contributed by Dr Hamish Smith

Presentation

Left sided testicular pain and swelling since this morning.

Patient Data

Age: 30 years
Gender: Male
Ultrasound

The left testis measures 27 x 39 x 23 mm (12.3 mL). Within the posterior testis, there is an ill-defined crescentic heterogeneous hypoechoic lesion measuring 22 x 21 x 5 mm. Mild internal vascularity is noted. There is increased surrounding echogenicity of the testicular parenchyma. The remainder of the testicle appears hyperemic with some focal microlithiasis evident. This is highly suspicious for a malignant lesion. 

Pathology

Macroscopic pathology

The left testes measure 43 x 35 x 20 mm, the external surface is smooth and inked green. On sectioning the testis showed an area of hemorrhage measuring 22 mm abutting the tunica albuginea.

Pathology

Microscopic pathology

The testicular parenchyma shows a dense interstitial infiltrate of lymphocytes which infiltrate and destroy the seminiferous tubules, the seminiferous tubules show reduced spermatogenesis. The blood vessels show florid vasculitis with areas of hemorrhage, fibrinoid necrosis of the vessel wall and intraluminal thrombus. Immunological staining is CD3 positive. 

Case Discussion

A 30-year-old gentleman presented with acute left-sided testicular pain and swelling. He denied any trauma or new sexual partners. He also denied any systemic symptoms and had no previous medical or surgical history. He had no familial history of rheumatological disease. On examination, his left testicle was swollen and very tender to palpation.

An ultrasound showed a mass like area in the testes thought to be malignant and so left sided orchiectomy was performed. The surprising diagnosis of testicular vasculitis was made histologically.

Testicular vasculitis is an uncommon cause of acute scrotal swelling and pain 1. Its peak incidence is around 40 years of age. Testicular vasculitis may be associated with either isolated vasculitis of the testicle only and as part of systemic vasculitis (most commonly polyarteritis nodosa) 2. Complete or segmental testicular infarction is a common complication of testicular vasculitis. Treatment is usually orchiectomy; however, treatment of a systemic vasculitis, if present, has been reported to save the testes in some cases 3.

In all patients presenting with testicular vasculitis, exclusion of an underlying disease is of paramount importance 3. This patient had no history or symptoms of systemic vasculitis or other autoimmune disease. Subsequent blood tests and rheumatological review found no evidence of underlying disease suggesting this to be a case of isolated testicular vasculitis.

 

Acknowledgements:

Dr Dougal Brown, radiologist

Dr Alka Sinha, pathologist

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Case information

rID: 58688
Published: 18th May 2018
Last edited: 14th Aug 2019
System: Urogenital
Inclusion in quiz mode: Included
Institution: Townsville hospital

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