Azoospermia in testicular sarcoidosis is an indication for corticosteroid therapy

Unnecessary orchiectomy due to atypical sarcoidosis manifesting as a unilateral scrotal mass: a case report and literature review

Sarcoidosis is a disease characterised primarily by lung tissue involvement. Extrapulmonary involvement, particularly in the genitourinary tract, is extremely rare, particularly when it comes to primary disease detection in this location. The gold standard in establishing a definitive diagnosis of sarcoidosis is a combination of the clinical picture, the results of imaging methods, and histopathological examination from the biopsy taken (thus ruling out other causes of granulomatous inflammation). However, it is common for the biopsy to be infeasible or for the patient to refuse such an examination, resulting in the neglect of this critical verification. We introduce the case of a young 29-year-old man of Czech nationality who had been complaining for some time about non-specific pain above the pubic bone and in the lower abdomen, which was combined with a painless enlargement of the right half of the scrotum. Due to suspected malignancy, it was, after considering clinical, imaging, and laboratory findings, decided to perform a radical orchiectomy as a treatment option. The histological examination revealed that it was not cancer, but rather a rare genitourinary form of extrapulmonary sarcoidosis. In this case, radical resection had been, therefore, unnecessary. We also present a review of the literature on published extrapulmonary, genitourinary, and testicular sarcoidosis cases. All the above demonstrates the importance of considering a possible atypical sarcoidosis manifestation and histological confirmation before pursuing radical solutions.

Case Report: Testicular Sarcoidosis: The Diagnostic Role of Contrast-Enhanced Ultrasound and Review of the Literature

Sarcoidosis is a multisystemic disease histologically characterized by non-caseating epithelioid granulomas and multinucleated giant cells; the etiology is still uncertain, and likely related to a complex interplay between environmental and genetic factors. The genitourinary system is affected in fewer than 0.2% of all clinically diagnosed cases of sarcoidosis and in 5% of those identified in autopsy studies. In this report, we describe a case of a 42–year-old male with one hypoechoic lesion per testis on B-mode evaluation; contrast-enhanced ultrasound (CEUS) on both lesions was carried out. During the early phase, the masses showed a hypovascular appearance as compared to the surrounding testicular tissue, maintaining the hypo-enhancement in the late phase. Tissue biopsy for pathological evaluation confirmed testicular sarcoid involvement, showing non-caseating granulomas. Allowing visualization of testicular microvascularisation, CEUS may play an important role in excluding malignancy, avoiding unnecessary aggressive treatment for benign conditions, such as sarcoidosis. A review of the literature of reported cases since 2004 of sarcoidosis involving the testis is also included.

Acute anejaculation, hypogonadism, and fertility preservation in the setting of neurosarcoidosis: case report and literature review

Objective

To examine fertility preservation techniques in the setting of neurosarcoidosis, and to review the impact of corticosteroid and methotrexate therapy on fertility.

Design

Case report of a patient with infertility secondary to anejaculation associated with spinal neurosarcoidosis, treated with systemic corticosteroids and methotrexate.

Setting

Academic tertiary-care hospital.

Patient(s)

A 39-year-old man presented with neurosarcoidosis complicated by acute anejaculation, erectile dysfunction, and hypogonadism. He underwent fertility consultation and sperm cryopreservation before initiating methotrexate therapy. His pretreatment total testosterone was low, at 157 ng/dL.

Intervention(s)

Unsuccessful pharmacologic therapy and penile vibratory stimulation (PVS) were followed by microdissection testicular sperm extraction (microTESE). Clomiphene was administered for optimization of spermatogenesis before microTESE.

Main Outcome Measure(s)

Vials of cryopreserved sperm, testis histopathology, and serum testosterone levels.

Result(s)

Eight vials of viable sperm were harvested by means of micro-TESE and cryopreserved. Despite intraoperative appearance of hypospermatogenesis, 90% of seminiferous tubules had active germ cell sloughing. Total testosterone increased to 278 ng/dL 2 months after initiating clomiphene.

Conclusion(s)

Conventional fertility preservation techniques may be effective in the setting of neurosarcoidosis-induced infertility owing to largely intact spermatogenesis. PVS, though not effective for this patient, should be considered along with electroejaculation, given high success rates in other patients with neurogenic anejaculation. Corticosteroid-mediated hypogonadism also must be considered in these patients, because it can negatively affect downstream spermatogenesis. In addition, evidence for the impact of paternal methotrexate exposure on fertility is limited and requires further investigation. As such, fertility consultation before initiating methotrexate is highly recommended.

Spontaneous Infertility Secondary to Testicular Sarcoidosis: A Case Report

Sarcoidosis is a multisystem disease that can affect any region of the body. Rarely, sarcoid involvement may even involve the male genitourinary tract, including the testicles. Testicular sarcoidosis causes spontaneous and severe effects on male fertility due to obstructive azoospermia. The case presented offers an insight into successful fertility treatment in a patient with obstructive testicular sarcoidosis. The patient and his partner presented to the clinic two years post successful natural conception of their first child with subsequent infertility. Within this period, the male partner was diagnosed with sarcoidosis and was on a treatment plan consisting of methotrexate and glucocorticoids. Complete azoospermia was confirmed via two separate semen analyses six weeks apart. The patient's testosterone (free and total), thyroid stimulating hormone (TSH), prolactin, follicle stimulating hormone (FSH), and luteinizing hormone (LH) were all within normal limits. With approval of pulmonology, methotrexate was discontinued for three months; however, subsequent semen analysis revealed no improvement. The patient was referred to urology, who confirmed the presence a palpable testicular nodule. Treatment of infertility was eventually achieved via testicular sperm aspiration (TESA) followed by in vitro fertilization (IVF) using intracytoplasmic sperm injection (ICSI). This treatment was successful in achieving one blastocyst and one morula, which were replaced via fresh transfer, resulting in a successful term singleton pregnancy. The possibility of obstructive azoospermia should be considered in males diagnosed with sarcoidosis who are seeking to preserve their reproductive potential.

Sexual function and reproduction can be impaired in men with rheumatic diseases: A systematic review

BACKGROUND

Information about the possible effect of rheumatic diseases on male sexual function and reproduction (sexual health) is scarce and difficult to summarize. Factors known to impair sexual health, such as inflammation, medication use and hypogonadism can be present in a significant proportion of male patients with rheumatic diseases.

OBJECTIVES

The objective of our study was to systematically review the literature for the influence of paternal rheumatic disease on sexual health, such as sexual function, reproductive hormones, male fertility, pregnancy and offspring outcomes.

DATA SOURCES

English language articles identified through Embase, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar and the Clinical trial registries of Europe and the USA published until February 2019.

STUDY APPRAISAL AND SYNTHESIS METHODS

Literature was synthesized in narrative form and in summary tables. Outcomes were categorized as: sexual function, reproductive hormones, fertility and pregnancy and offspring outcomes. Results are presented per category and per disease.

RESULTS

9735 articles were identified with our search strategy. After removal of duplicates, excluding articles by screening titles and abstracts and assessing eligibility by reading 289 fulltext articles, 87 articles fulfilled the eligibility criteria. All included studies enrolled patients diagnosed with a rheumatic disease and had results at least on one of the outcome categories. Sexual function was the most common category, followed by reproductive hormones, fertility and pregnancy and offspring outcomes. Sexual function is impaired in a high proportion of patients with rheumatic diseases. This was statistically significant in most of the studies where a control group was available. Clinically relevant abnormalities in reproductive hormones were mainly identified in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) and a positive correlation with disease activity were reported. Semen quality in men with rheumatic diseases can be impaired in patients with SLE, SpA, sarcoidosis, BD and MWS. Sperm count and motility were the most common semen quality parameters affected. No negative effect of paternal RA and vasculitis on pregnancy outcomes were reported in 3 studies. No studies reporting the effect of paternal disease on offspring outcomes were identified.

LIMITATIONS

Most of the studies included in this review suffer from an inconsistent methodological quality, definitions of outcomes varied in several studies, a wide variety of screening questionnaires and/or diagnostic tools were used and results might only apply to the specific populations that were studied.

CONCLUSIONS

This systematic review suggests that sexual health is impaired in men with rheumatic diseases. The degree and extent of sexual health impairment vary per disease. More research is needed to fully understand the link between rheumatic diseases and impaired male sexual health. Meanwhile, rheumatologists should be aware of this association and discuss it with their patients.

IMPLICATIONS OF KEY FINDINGS

Sexual health of men with rheumatic diseases can be impaired by the disease itself. Especially in men trying to conceive, information on sexual function, reproductive hormones and sperm quality are needed to identify these problems. Treatment resulting in lower disease activity can improve overall sexual health in man with rheumatic diseases and facilitate their journey to fatherhood.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2018 CRD42018099845.

Intrascrotal and osseous sarcoidosis mimicking intrascrotal organ cancer and bony metastasis

We report a case of sarcoidosis with concomitant epididymis, testes, and phalanxes involvement mimicking intrascrotal organ cancer and metastatic bony disease. A 23-year-old man developed blurred vision and hyperemia of the left eye, and was diagnosed as having left iritis. A chest computed tomography scan detected bilateral hilar lymphadenopathy and lung nodular shadows. A transbronchial lung biopsy revealed a non-caseating granuloma and he was diagnosed with sarcoidosis. One year after the onset of his eye symptoms, he noticed enlargement of his right scrotum. Magnetic resonance imaging detected lesions of the right epididymis, bilateral testes, and bilateral phalanxes. A technetium-99m scintigram revealed a high accumulation in the bilateral bones of extremities. These radiological findings mimicked intrascrotal organ cancer and metastatic bony disease. Pathologic evaluation following the right epididymectomy revealed non-caseating granulomas compatible with sarcoidosis. Three and half years after the appearance of intrascrotal and bony lesions, they improved spontaneously. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 373-376).

Genitourinary sarcoidosis: An essential review for the practicing clinician

INTRODUCTION

Sarcoidosis is a multisystem disease that commonly involves the lungs, but may also present with extrapulmonary manifestations. Genitourinary (GU) tract involvement has been traditionally thought to be rare, but that view may underestimate the true prevalence of the disease due to the often, silent presentation thereof.

METHODS

The literature pertaining to sarcoidosis from the general systemic point of view, etiology and therapy and with regard to specific organs was reviewed by identifying key words in a PubMed search. That material with special relevance to the Indian experience was emphasized.

RESULTS

There are a number of isolated case reports in the literature describing symptomatic and asymptomatic GU tract sarcoidosis. The world literature associated with the generalized syndrome was reviewed and summarized. Specific aspects of GU involvement are presented for each organ of the GU tract.

CONCLUSIONS

It is critical for the practicing clinician to have a working knowledge of the clinical manifestations of this disease as it involves the GU tract, as well as to be able to distinguish it from tuberculosis and the various malignancies that affect this organ system.

Testicular sarcoidosis masquerading as testicular carcinoma

We present a case of a 27-year-old man with a history of weight loss. A chest x-ray demonstrated hilar lymphadenopathy and he was treated with anti tuberculosis treatment. He noticed a painless left scrotal swelling and a scrotal ultrasound scan raised the possibility of testicular cancer. He underwent an orchidectomy and histology confirmed a testicular sarcoidosis. He was commenced on steroid treatment.

Corticosteroid therapy improves the outcome of semen analysis in an oligozoospermic patient with epididymal sarcoidosis

Sarcoidosis is a multisystem, inflammatory disorder characterized by the presence of noncaseating epithelioid granulomas. Sarcoidosis can involve the genitourinary system by affecting the kidney and genitals. Most characteristic genital lesions proceed to granuloma and can comprise the epididymis, testis, and vas deferens. Few case reports have been published on this rare entity. We report a case in which a man presented with bilateral epididymal sarcoidosis and severe oligospermia. Corticosteroid treatment, which was applied in gradually decreasing doses for 6 months, dissolved the testicular granuloma. Consequently, semen analysis demonstrated a significant increase in the sperm count to within normal limits.

Testicular masses in a man with a plausible sarcoidosis

Genitourinary involvement with sarcoidosis is very rare. The objective of this report was to present a case of a patient with testicular swelling. The patient was an infertile 42-year-old man with bilateral testicular swelling. Semen analysis in the past 10 years revealed no abnormality; however, gradually he became azoospermic in 3 years. A diagnosis of sarcoidosis made on the basis of hilar and mediastinal lymphadenopathy in chest CT scan was confirmed through testicular and epididymal biopsy. Testicular masses vanished after administering steroids, and azoospermia recovered. To conclude, although genitourinary sarcoidosis is rare, it must be kept in mind in patients with confirmed sarcoidosis.

Testicular Sarcoidosis: Sonographic Findings

Testicular sarcoidosis is a rare but benign entity. It is often mistaken for testicular neoplasm, leading to orchiectomy. It is, therefore, extremely important to identify and correctly diagnose testicular sarcoidosis on sonography to avoid unnecessary orchiectomy. This case study reports a young patient who had a prior history of unilateral orchiectomy for cryporchidism and presented with testicular lesions on the contralateral testis. He was later found to have skin lesions and chest symptoms that led to a diagnosis of sarcoidosis.

Sarcoidosis presenting as intrascrotal mass: case report and review

Sarcoidosis is a multisystemic disease that usually involves the lungs and lymph nodes, but almost any organ can be involved. Genitourinary involvement with sarcoidosis is extremely rare. We report the case of a 30-year-old African-American male who presented with a right-sided intrascrotal mass and diffuse lymphadenopathy. On further workup, he was found to have sarcoidosis. Two months of corticosteroid treatment resulted in the disappearance of his intrascrotal mass.