A 32-year-old Asian male presented with a 1-month history of painless bilateral scrotal swelling. The patient was diagnosed with lung sarcoidosis (stage II) 2 years prior to presentation to our hospital and he took no regular medications. There was no family history of sarcoidosis. His height and weight were 171 cm and 87.4 kg, respectively. The physical examination revealed painless bilateral scrotal swelling and palpable 1- to 1.5-cm testicular masses. Initial blood tests, including complete blood count, electrolytes, renal function, and C-reactive protein levels, were within the normal limits, but slight liver dysfunction due to fatty liver was observed (AST 41 U/L, ALT 71 U/L, and gamma-GTP 72 U/L). Serum levels of testosterone, follicle-stimulating hormone, luteinizing hormone, and prolactin were within the normal range. Serum tumor markers, including AFP, beta-HCG, and LDH, were within the normal limits. The soluble IL-2 receptor level was mildly increased to 686 U/mL (normal range, 145-519 U/L) and the serum ACE level increased to 26 U/mL (normal range, 8.3-21.4 U/L). The rapid plasma reagin test and Treponema pallidum hemagglutination assay were negative. Tuberculosis skin tests and serology findings regarding hepatitis C and B were also negative.
Ultrasonography revealed scattered hypoechoic mass lesions in both testes (Fig. 1). A nodular lesion with an internal cavity in the left upper lobe of the lung, hilar lymph nodes, and para-aortic lymph node swelling was noted on chest and abdominal CT (Fig. 2a,b). MRI demonstrated scattered T2 low-signal areas in both testes. There was an abnormal accumulation in both testes on gallium-67 scintigraphy. We suspected testicular sarcoidosis and testicular biopsy was performed. The lesions were identified by ultrasonography, and we incised the scrotum and the tunica albuginea of the testes. There were hard nodules with clear boundaries and the lesions were easily strippable. As the pathological diagnosis during the biopsy was suspected to be sarcoidosis without malignancy, we collected some nodules and finished the biopsy. Pathologically, noncaseating epithelial cells with multinucleated giant cells, and some normal spermatogonia and spermatocytes were observed in both testes, and we diagnosed the patient with testicular sarcoidosis without any tumor cells (Fig. 3). Semen examination was performed after the biopsy, demonstrating oligospermia (2 x 106/mL).
As the patient wished to have children, we administered corticosteroids. He initially received 40 mg of oral prednisone/day, and the dose was reduced to a maintenance dose of 2.5 mg/day during the 7 months of treatment. On CT examination after treatment, the left lung nodule, hilar lymph node, and para-aortic lymph node had shrunk (Fig. 2c,d), and no abnormal accumulation in either testis was observed on gallium-67 scintigraphy. Mild improvement of the sperm count of 7 x 106/mL was noted by semen examination. We encouraged the patient to receive assisted reproductive treatments, such as intracytoplasmic sperm injection, as a treatment option for oligozoospermia, but he refused.
CT scans of the chest and abdomen. A nodular lesion with an internal cavity in the left upper lobe of the lung , hilar lymph nodes, and.