AJR 2005; 184:552-553
© American Roentgen Ray Society
Radiologic–Pathologic Conference of Wilford Hall Medical
Center |
Coccidioidomycosis of the Epididymis and Testis
Thomas M. Dykes1,
Alan B. Stone1 and
Edith D. Canby-Hagino2
1 Department of Radiology, 59th Medical Wing, Wilford Hall Medical Center, 2200
Bergquist Dr., Ste. 1, Lackland AFB, TX 78236-5300.
2 Department of Urology, 59th Medical Wing, Wilford Hall Medical Center,
Lackland AFB, TX 78236-5300.
Received June 22, 2004;
accepted after revision August 25, 2004.
Address correspondence to T. M. Dykes
(thomas.dykes{at}lackland.af.mil).
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or representing the views of
the Department of the Air Force.
A 78-year-old man with a history of benign prostate hypertrophy presented
with a painless, firm right scrotal mass on routine physical examination.
Scrotal sonography (Figs. 1A
and 1B) with a linear 10-MHz
transducer showed a focally enlarged lower pole of the epididymis with
heterogeneous echotexture compared with the rest of the epididymis and a
moderate-sized right hydrocele. Directly contiguous with the lower pole
epididymal mass was a 1.8-cm hypoechoic mass in the lower pole of the right
testicle. There was also a subtle, striated echotexture pattern in the right
testicle compared with the left. The left testicle and epididymis were normal
except for small epididymal head cysts and a small hydrocele. Because of the
concern for a primary testicular neoplasm, abdominal and pelvic CT was
performed and showed no retroperitoneal lymphadenopathy.
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Fig. 1A. —78-year-old man who presented with painless, firm right
scrotal mass on routine physical examination. Longitudinal sonogram obtained
through lower pole of right testicle shows enlarged epididymis tail (EPI TAIL)
with heterogeneous echotexture (curved arrow) and hypoechoic mass in
lower pole of right testicle (straight arrows).
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Fig. 1B. —78-year-old man who presented with painless, firm right
scrotal mass on routine physical examination. Longitudinal sonogram obtained
through medial lower pole of right testicle shows subtle hypoechoic, linear
striations in testicular parenchyma (straight arrow) and portion of
testicular mass (curved arrow). Hydrocele is also present.
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Right orchiectomy was performed. The result of gross pathologic examination
was a 1.3-cm, yellow-tan cerebriform mass within the inferior medial pole of
the right testis arising at the junction of the distal epididymis and the
lower pole testis. The tumor appeared to involve the epididymis but did not
extend through the tunica vaginalis. There was also a 2.0-cm pale area in the
upper right testicular pole. Representative sections from the distal
epididymis and lower testicular pole disclosed widespread caseating
granulomatous inflammation. Numerous 10-µm thick-walled spherules
containing multiple endospores were observed within the cytoplasm of
constituent epithelioid histiocytes (Figs.
1C and
1D). These features are
diagnostic of Coccidioides organisms. No testicular neoplasm was
identified. The pale area in the upper testicular pole recognized on gross
examination showed focal seminiferous tubule atrophy with intervening clusters
of interstitial Leydig's cells. After surgery, complement-fixation blood
titers were drawn showing elevated levels and serologic worsening compared
with titers obtained a decade previously, consistent with disseminated
Coccidioides immitis disease.
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Fig. 1C. —78-year-old man who presented with painless, firm right
scrotal mass on routine physical examination. High-power photomicrograph of
testis shows granulomatous inflammation with lymphocytes infiltrating
interstitium (white arrow) and multinucleated giant cell (black
arrow) involving seminiferous tubule and surrounding stroma. (H and E,
x400).
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Fig. 1D. —78-year-old man who presented with painless, firm right
scrotal mass on routine physical examination. High-power photomicrograph shows
granulomatous inflammation in epididymal stroma with spherule containing
multiple endospores (arrow), typical of Coccidioides
organism. (H and E, x400).
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It is estimated that there are more than 100,000 new cases of C.
immitis infections annually in the United States
[1]. Symptomatic extrapulmonary
disease develops in less than 1% of people infected with C. immitis
and is due to hematogenous spread of the fungus
[1]. Although disseminated
C. immitis commonly involves the genitourinary system, scrotal
disease is rare, reported in only 1.5% of cases in a postmortem study
[2]. Clinical symptoms of
genitourinary disseminated disease are generally referable to the lower
urinary tract with voiding dysfunction or scrotal swelling
[2].
To the best of our knowledge, there are no previous reports on the
sonographic findings of C. immitis infection of the scrotum. This
case shows a focal mass of mixed echotexture that involves both the epididymis
and contiguous testicular parenchyma. Kim et al.
[3] reported on the sonographic
findings of tuberculous epididymitis and epidymoorchitis, describing findings
similar to those in this patient. They postulated that the sonographic
features that characterize tuberculous infection of the epididymis were
different from those of nontuberculous epididymitis because of the caseating
necrosis and fibrosis associated with tuberculous infection. The inflammatory
response to C. immitis described in the literature
[1] and in our patient also
consists of caseating granulomatous inflammation and mononuclear cell
infiltration. Our case also shows subtle testicular striations on sonography.
Casalino and Kim [4] reported
that testicular striations have the same anatomic distribution as the
interlobular septa of the testicle and causes could include primary testicular
neoplasm, lymphoma, acute orchitis, and fibrosis.
Chronic granulomatous infection must be considered in the differential
diagnosis of a focal scrotal mass. It is important to consider disseminated
C. immitis as a cause for a focal scrotal mass because adequate
treatment includes systemic antifungal therapy and surgical resection of
infected scrotal contents
[2].
References
- Chiller TM, Galgiani JN, Stevens DA. Coccidioidomycosis.
Infect Dis Clin North Am2003; 17:41
–57[Medline]
- Wise GJ, Talluri GS, Marella VK. Fungal Infections of the
genitourinary system: manifestations, diagnosis and treatment. Urol
Clin North Am 1999;26:701
–718[Medline]
- Kim SH, Pollack HM, Cho KS, Pollack MS, Han MC. Tuberculous
epididymitis and epididymo-orchitis: sonographic findings. J
Urol 1993;150:81
–84[Medline]
- Casalino DD, Kim R. Clinical importance of a unilateral striated
pattern seen on sonography of the testicle. AJR2002; 178:927
–930[Abstract/Free Full Text]
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