Pulmonary thromboembolism secondary to left spermatic vein thrombosis: a case report

Spontaneous Bilateral Spermatic Vein Thrombosis: A Rare Clinical Presentation

Cases of acute scrotum presenting to the emergency department are usually due to testicular torsion, complicated hernia, or epididymo-orchitis. Thrombosis of the spermatic vein is an uncommon entity and most of the cases reported to date are of unilateral involvement. Here, we present an extremely rare case of spontaneous bilateral spermatic vein thrombosis, which was diagnosed by a Doppler ultrasound of the testes. This article highlights its clinical presentation, radiological imaging, etiology, and management.

Trombosis de la vena espermática derecha. Primer caso clínico reportado en Colombia

Introducción. La trombosis de la vena espermática (TVE) es una entidad muy poco frecuente de la cual no se tienen datos epidemiológicos específicos. Su presentación es de predominio izquierdo, en la mayoría de los casos su causa es desconocida y su diagnóstico suele realizarse por exclusión en el estudio del escroto agudo. A continuación, se presenta el primer caso documentado de TVE en Colombia y uno de los pocos de lateralidad derecha en el mundo. Presentación del caso. Hombre de 21 años quien consultó al servicio de urgencias de una institución de tercer nivel de atención de Bogotá, Colombia, por un cuadro clínico de una semana de evolución consistente en dolor en región inguinoescrotal derecha que aumentó progresivamente de intensidad y estuvo acompañado de un pico febril no cuantificado; el paciente indicó como único antecedente médico un trauma craneoencefálico leve sin secuelas a los 20 años. Se realizó estudio con ecografía Doppler testicular en donde se observó trombosis del cordón espermático derecho. Se inició manejó con antibioticoterapia, heparinas de bajo peso molecular y cumarínicos, con lo cual se obtuvo una adecuada respuesta y la resolución del cuadro. Conclusión. La TVE representa un reto diagnóstico, por lo que se requiere de una alta sospecha clínica, la cual se genera teniendo conocimiento de la entidad e incluyéndola en el diagnóstico diferencial del escroto agudo. La ecografía Doppler es una herramienta fundamental para diagnosticar TVE, además permite iniciar un tratamiento conservador oportuno, seguro y eficaz que evite desenlaces desfavorables para el paciente, lo que resulta ser costo-efectivo.

Bilateral spontaneous thrombosis of the pampiniform plexus mimicking incarcerated inguinal hernia: case report of a rare condition and literature review

Background

Pampiniform plexus thrombosis is a very rare disease (only less than 25 published cases are available till date), and it is a diagnostic dilemma. The present case is an unusual condition of an elderly gentleman who was finally diagnosed as a case of spontaneous thrombosis of bilateral pampiniform plexus and was managed conservatively. Literature was reviewed to explore potential etiologies and therapeutic strategies.

Case presentation

A 65-year-old afebrile gentleman, laborer (in brick industry), and non-smoker with no previous major health problems was admitted with swelling in the bilateral inguinal region. The swelling had started one and half months ago. He had developed severe pain over the swelling for last 1 day with tenderness and indurations. Neither he had history of previous surgeries, chronic cough, dysuria, prostatism, and trauma nor he presented any thrombogenic factors. There was no history of vomiting, abdominal pain, and obstipation. Physical examination revealed normotensive person with BMI of 22.5, was significant only for one tender, movable, and firm to hard 10 cm × 3 cm mass extending from the left deep inguinal ring up to the upper pole of the testis in the scrotum. Another 5 cm × 3 cm mass of similar characteristics was found extending from deep inguinal ring up to the root of the scrotum on right side. The testes and prostate were normal on palpation.

On the contrary to preoperative USG, which clinched suspicion of incarcerated inguinal hernia, a thrombosed pampiniform plexus without any evidence of hernia sac was found on the left side during inguino-scrotal exploration. Wound was closed without doing any further procedure. Contralateral inguino-scrotal exploration was spared considering same nature of disease. Postoperative Doppler ultrasonography confirmed the diagnosis of bilateral thrombosed pampiniform plexus. MDCT of whole abdomen revealed no abnormality other than bilateral spermatic cord thrombosis. Blood thrombophilia screening came normal. The subject had an uneventful postoperative hospital course. With 2 years of follow-up, the gentleman is doing well, remaining asymptomatic and had returned to his usual life.

Conclusions

Due to extreme rarity, spontaneous thrombosis of the pampiniform plexus may be a diagnostic dilemma and requires a high index of suspicion. Doppler ultrasound is the initial investigation of choice. In the absence of other concomitant disease, beginning the treatment conservatively instead of excising the thrombosed segment is more suitable.

[Right spermatic vein thrombosis. Revision of literature regarding a specific case]

Acute thrombophlebitis of spermatic vein is an unusual pathology involving, in most of the cases, the left side, and whose etiology remains uncertain. Most of them are found during a a differential diagnosis in acute testicular pain. We introduce the case of a 29 years old male with abusive cocaine consumption, admitted to hospital due to severe testicular pain. Doppler-ultrasound examination was undertaken, showing right spermatic vein flux alteration. Conservative management was decided and anticoagulant and non-esteroidal anti-inflammatory drugs were started. Eco-doppler is the most specific and sensible technique for diagnosis of these cases, while TC can always confirm etiologic diagnosis. Treatment was initially conservative based on anticoagulation. Hematological study is necessary in order to determine coagulation alterations.

Testicular vein thrombosis: Incidence of recurrent venous thromboembolism and survival

PURPOSE

Testicular vein thrombosis (TVT) etiology, recurrence, and survival were compared with lower extremity deep vein thrombosis (DVT) in order to determine whether treatment guidelines for DVT could be applied to TVT.

PATIENTS AND METHODS

An inception cohort of patients with confirmed TVT (January 1995-October 2015) was compared to a control group of patients with lower extremity DVT matched by age, gender, and diagnosis date.

RESULTS

Thirty-nine men with TVT were identified; 15 (38%) with isolated TVT. Left testicular vein was affected in 77% patients; there were no cases of bilateral TVT. Cancer was over twofold more common in TVT patients (59% vs 28%, P = .01). Most cancers (78%) involved organs in proximity to the testicular vein. Although TVT patients were less frequently treated with anticoagulants (49% vs 97%, P = .0001), recurrence rates were similar to DVT group (TVT 4.2 vs DVT 1.1 per 100 patient-years, P = .11). Despite higher cancer prevalence, survival rates were similar between groups (31% vs 28%; P = .34). Major bleeding events were rare (one patient per group).

CONCLUSIONS

Identifying TVT should prompt a search for a regional malignancy. Despite the high cancer prevalence and low utilization of anticoagulants, recurrent venous thrombosis and mortality rates are similar to DVT patients.

Thrombotic and Nonthrombotic Types of Intratesticular Varicoceles: Value of Sonography for the Diagnosis

An intratesticular varicocele is an uncommon entity, and its clinical importance remains unclear. The diagnosis can be made in the case of an intratesticular tortuous vein that shows retrograde flow on color Doppler sonography. The anatomic location and course of the intratesticular varicocele within the testicular parenchyma and its association with the existence of an ipsilateral extratesticular varicocele may vary among patients. The pathophysiologic mechanisms remain unclear; however, it may be questioned whether there is an association between testicular atrophy and intratesticular varicocele development. Although the diagnosis is usually made incidentally, patients may rarely present with acute scrotal pain due to acute thrombosis of an intratesticular varicocele.

Isolated thrombosis of right spermatic vein with underlying Factor V Leiden mutation

Spermatic vein thrombosis is a very uncommon clinical entity. Most cases involve the left side. Herein, we present an unusual case of a young man who presented with spermatic vein thrombosis on the right side with an underlying Factor V Leiden mutation. To our knowledge, it is the first case in the literature.