A 31-year-old male came to our clinic for suspicious testicular masses. Frozen-section examination of an excisional biopsy revealed inflammatory tissue, so we did not perform orchifuniclectomy. Definitive hystopatology revealed mio-fibroblastic nodules, which were considered consistent with testicular localization of luetic lesions. The patient was tested for syphilis and was found to be positive. HIV and other sexually transmitted diseases (STDs) tests were negative. He underwent antibiotic treatment and is doing well.
Urologia 2015; 82(4): 245 - 246
Article Type: CASE REPORT
Article Subject: CASE REPORTS/Casi clinici
AuthorsAlessandro Morlacco, Alberto De Gobbi, Fabrizio Dal Moro, Filiberto Zattoni
- • Accepted on 26/05/2015
- • Available online on 04/08/2015
- • Published in print on 02/12/2015
This article is available as full text PDF.
Testicular masses are a common finding in urological clinical practice. In most cases, they are a simple issue to deal with. In some cases, they can be very challenging. That was what happened to us: a very rare presentation of an uncommon disease. Sexually transmitted diseases (STDs) are an uncommon cause of testicular lesions. Among STDs, syphilis is considered a very rare occurrence in non-HIV European males. Furthermore, testicular luetic lesions are anecdotical in scientific literature. We therefore think that our case could be useful for throwing light on this uncommon clinical situation.
A 31-year-old man came to our clinic for pain and swelling in his right testicle of 2 weeks duration. His familiar anamnesis and past medical history were negative and he was not taking medications at home. He had a nonprotected sexual intercourse with a man 6 weeks before. He denied fever, dysuria and any other symptom suggestive for STD. The physical examination was normal except for swelling and tenderness to palpation in his right testicle.
A testicular US of right testis showed a 10 mm hypoechoic and vascularized nodule, close to mediastinum testis. Another similar nodule was evident at lower pole, and hypoechoic stripes were present between the two lesions. Both epididimys and left testicle were normal. Serum markers (alpha-fetoprotein, beta-human chorionic gonadotropin, lactatedehydrogenase) were between normal ranges.
Every testicular mass should be considered suspicious for testicular neoplasm, until proved otherwise. For this reason, a surgical exploration is mandatory when the presence of testicular cancer could not be excluded on the basis of clinical features, imaging and laboratory investigations. Other possible causes of testicular masses are post-traumatic, or malformative and vascular diseases (intratesticular haematoma, testicular angioma, testicular angiofibroma, testicular infarction), which can be usually distinguished from testicular neoplasm by their imaging appearance. Furthermore, most of the time, the presence of a testicular inflammatory/infectious lesion (testicular abscess, testicular tuberculosis, intratesticular parasitosis, sarcoidosis) may be recognized on the basis of patient’s history, physical examination, laboratory and/or imaging studies.
In our case, the presence of a testicular neoplasm could not be excluded, so we decided to perform an explorative inguinotomy. When right testis was exteriorized, his external appearance was normal, while an intraoperative US confirmed the presence of the two masses seen before. We therefore enucleated one of the two, which was sent for frozen-section examination. The results were consistent with an inflammatory lesion, so we enucleated the second mass and sent it for definitive examination, while the testicle was sutured and replaced in the scrotum.
Outcome and follow-up
In the postoperative phase, the patient became febrile (38.5°C). Local physical examination was unremarkable and the fever resolved after 2 days of oral antibiotics (amoxicilline along with ciprofloxacin); the patient was then discharged on postoperative day 3.
Definitive hystopathological examination showed a myofibroblastic inflammatory lesion with a diffuse proliferation of lymphocites, macrophages and granulocytes in a myiofibroblastic network. According to two separate pathologists (one expert in uropathology and one expert in haemopathology), this feature was consistent with secondary syphilitic lesion. As soon as we received this result, we called the patient and we strongly advised him to undergo STD test. The results were negative for viral STDs (including HIV) and for gonococcal disease, while both VDRL (Venereal Disease Research-Laboratory) and TPHA (Treponema Pallidum Haemoagglutination Assay) showed a marked positivity. We re-examined the patient; the physical examination was normal, and he denied any history of genital ulcers, cutaneous rash and/or systemic symptoms (fever, malaise). No other lesions were present. The patient was then evaluated by an infectious disease specialist and begun antibiotic treatment with Penicillin G twice weekly for 3 weeks. He is now doing well at 2 months follow-up.
In literature, some cases are about HIV patients (2, 3). Even more rare is the presence of testicular syphilis in non-HIV patients. The disease is characterised by a hard, indolent testicular nodule, or is an incidental finding during a testicular ultrasound. It rarely presents with pain or signs of infection (4), and it is usually preceded by other manifestations of systemic syphilis (5). Our case is a peculiar example of how the testicular manifestation could be the first sign of the disease. The approach was surgical in order to investigate the presence of testicular cancer, the most common cause of testicular mass.
There are cases treated conservatively and described in the literature (5), although we believe that this approach can be dangerous to the patient because the possible presence of a cancer would be not diagnosed promptly. In some other cases, radical orchidectomy was performed, and the definitive examination eventually showed syphilis (1, 6, 8, 9).
Despite being aware of the rarity of the pathological type of event, we believe that syphilis should be considered in the differential diagnosis of a testicular mass when histology shows an ‘inflammatory situation’. In some cases, when intraoperative diagnosis is uncertain and the lesion is highly suspicious, radical orchidectomy is warranted.
- Morlacco, Alessandro [PubMed] [Google Scholar] , * Corresponding Author (firstname.lastname@example.org)
- De Gobbi, Alberto [PubMed] [Google Scholar]
- Dal Moro, Fabrizio [PubMed] [Google Scholar]
- Zattoni, Filiberto [PubMed] [Google Scholar]
Urologic Clinic, Padua University Hospital, Padua - Italy