Figure 1
Teaching Case
SectionUroradiology & genital male imaging
Case TypeClinical Cases
AuthorsSally Emad-Eldin1, Omar Abdelaziz1, Mohamed Shokr2, Ibrahim M. Fahmy2, Sameh A.Z. Hanna1
Connected authors
25 years, male
A 25-year-old male patient with past history of lepromatous leprosy infection of the skin 5 years before presented with primary infertility. Local examination revealed hard testes with no palpable masses. Semen analysis showed azoospermia. Laboratory investigations revealed low normal testosterone level, elevated FSH level and negative tumour markers.
Testicular fibrosis
Granulomatous orchitis (tuberculous
fungal
parasitic)
Sarcoidosis
Scrotal US showed multiple bilateral hypoechoic lesions (Fig. 1), with no vascularity on colour Doppler examination.
MRI examination of the scrotum before and after IV contrast revealed relatively small-sized testes bilaterally, the testicular volume was 7.5 cc and 7.4 cc on the left and right side respectively. They showed multiple variable-sized lesions of low signal on T1WI (Fig. 2a), very low signal on T2WI (Fig. 2b), with no appreciable enhancement after contrast administration (Fig. 2c).
An open biopsy with frozen section analysis was performed. Pathology revealed marked hylanosis of the basement membrane of the seminiferous tubules. Some tubules showed complete sclerosis. Few tubules showed Sertoli cells only with marked atrophic changes. The interstitium showed chronic inflammatory cell infiltration with fibrosis (Fig. 3a, b).
MRI examination of the scrotum before and after IV contrast revealed relatively small-sized testes bilaterally, the testicular volume was 7.5 cc and 7.4 cc on the left and right side respectively. They showed multiple variable-sized lesions of low signal on T1WI (Fig. 2a), very low signal on T2WI (Fig. 2b), with no appreciable enhancement after contrast administration (Fig. 2c).
An open biopsy with frozen section analysis was performed. Pathology revealed marked hylanosis of the basement membrane of the seminiferous tubules. Some tubules showed complete sclerosis. Few tubules showed Sertoli cells only with marked atrophic changes. The interstitium showed chronic inflammatory cell infiltration with fibrosis (Fig. 3a, b).
Leprosy, caused by Mycobacterium leprae, is a chronic disease with varied presentations [1]. Involvement of the male genitalia, particularly of the gonads, is well known in leprosy [2]. As it is presumed that leprosy bacilli reach the testes via the blood stream, bilateral testicular involvement should be suspected [3]. Non-inflammatory orchitis, a complication of lepromatous infection, consists of tubular atrophy and sclerosis resulting from diffuse interstitial infiltration of foamy macrophages [4]. In advanced cases the testes are reported to be small, firm and atrophic [3].
Azoospermia and sterility have also been known to occur in patients with leprosy [5]. Azoospermia is mainly attributed to the testicular involvement and not to obstruction of the epididymis as occurs in cases of tuberculous epididymitis [3].
Testicular fibrosis can occur secondary to trauma, inflammation, or incomplete testicular torsion. Other causes of testicular fibrosis include radiation therapy [6] and post-biopsy changes [7].
The normal adult testis is ovoid and measures 3 cm in anterior-posterior dimension, 2–4 cm in width, and 3–5 cm in length [8]. Most testes with fibrosis are either small or normal-sized [9].
Testicular fibrosis can be a worrisome finding at ultrasound examination [10]. There is significant overlap in the sonographic appearance of benign fibrotic lesions and testicular malignancies [11]. A variety of sonographic patterns are found, including focal hypoechoic or hyperechoic lesions and diffuse heterogeneity of the testicular parenchyma [7, 12].
Through the use of different sequence types and the administration of gadolinium, MRI can be used to characterize the pattern of scrotal disorders [13]. The MRI criteria used to characterize testicular fibrosis are typical, including the presence of lesions of low and very low signal intensity on T1WI and T2WI, respectively, which do not become enhanced after gadolinium administration [14, 15].
In this case, the presence of bilateral non-enhancing lesions of very low T2 signal intensity were suggestive of testicular fibrosis of previous inflammatory sequel.
Azoospermia and sterility have also been known to occur in patients with leprosy [5]. Azoospermia is mainly attributed to the testicular involvement and not to obstruction of the epididymis as occurs in cases of tuberculous epididymitis [3].
Testicular fibrosis can occur secondary to trauma, inflammation, or incomplete testicular torsion. Other causes of testicular fibrosis include radiation therapy [6] and post-biopsy changes [7].
The normal adult testis is ovoid and measures 3 cm in anterior-posterior dimension, 2–4 cm in width, and 3–5 cm in length [8]. Most testes with fibrosis are either small or normal-sized [9].
Testicular fibrosis can be a worrisome finding at ultrasound examination [10]. There is significant overlap in the sonographic appearance of benign fibrotic lesions and testicular malignancies [11]. A variety of sonographic patterns are found, including focal hypoechoic or hyperechoic lesions and diffuse heterogeneity of the testicular parenchyma [7, 12].
Through the use of different sequence types and the administration of gadolinium, MRI can be used to characterize the pattern of scrotal disorders [13]. The MRI criteria used to characterize testicular fibrosis are typical, including the presence of lesions of low and very low signal intensity on T1WI and T2WI, respectively, which do not become enhanced after gadolinium administration [14, 15].
In this case, the presence of bilateral non-enhancing lesions of very low T2 signal intensity were suggestive of testicular fibrosis of previous inflammatory sequel.
References
[1] Patnaik S, Mohanty I, Bal AK. (2013) Tuberculoid leprosy of glans penis. Indian Journal of Medical Specialities. Indian Journal of Medical Specialities 4(2):292-294
[2] Paudyal P, Shrestha S, Agarwal M, Kafle SU, Karki S, Upadhyaya P, Agarwal S, Pradhan A. (2013) Histoid leprosy on scrotal skin: an unusual case. Int J Infect Microbiol 2(2):64-67
[3] Nigam P, Mukhija RD, Gupta AK, Dayal SG, Goyal BM (1984) Gonadal involvement in leprosy- study of gynecomastia, testicular and epididymal involvement and therapeutic efficacy of indigenous drugs. Hansenol Int 9(1-2):10-20 (PMID: 6600032)
[4] Ridley, D. S. and Job, C. K. (1994) The pathology of leprosy. Leprosy. 2nd edn. Hastings, R. C., ed. Edinburgh: Churchill Livingstone 217
[5] Nigam, P , Mukhija RD, Kapoor KK, Kumar A, Sarkari N, Gupta A K and Mishra SD (1988) Male gonads in leprosy—a clinicopathological study. Indian J. Lepr 60 (1): 77-83 (PMID: 3204278)
[6] Aguado A, Grant TH, Miller FH, Garnett J (2005) Radiation-induced fibrosis of the spermatic cord: sonographic and MRI findings. AJR Am J Roentgenol 184:S102–103 (PMID: 15727994)
[7] Yagan N (2000) Testicular US findings after biopsy. Radiology 215:768–773
[8] Kim W, Rosen MA, Langer JE, Banner MP, Siegelman ES, Ramchandani P. (2007) US MR imaging correlation in pathologic conditions of the scrotum. Radiographics 27(5):1239-53 (PMID: 17848688)
[9] Bhatt S, Jafri SZ, Wasserman N, Dogra VS (2011) Imaging of non-neoplastic intratesticular masses. Diagn Interv Radiol 17:52–63 (PMID: 20677130)
[10] Tsili AC, Argyropoulou MI , Giannakis D, Sofikitis N, Tsampoulas K (2010) MRI in the characterization and local Staging of Testicular Neoplasms. AJR Am J Roentgenol 194:682–689 (PMID: 20173145)
[11] Einstein DM, Paushter DM, Singer AA, Thomas AJ, Levin HS (1992) Fibrotic lesions of the testicle: sonographic patterns mimicking malignancy. Urol Radiol 14(3):205-10 (PMID: 1290214)
[12] Casalino DD, Kim R (2002) Clinical importance of a unilateral striated pattern seen on sonography of the testicle. AJR Am J Roentgenol 178:927–930 (PMID: 11906874)
[13] Müller-Leisse C, Bohndorf K, Stargardt A, et al. (1994) Gadolinium-enhanced T1-weighted versus T2-weighted imaging of scrotal disorders: is there an indication for MR imaging?. J Magn Reson Imaging 4:389–395 (PMID: 8061438)
[14] Woodward PJ, Sohaey R, O’Donoghue MJ, Green DE. (2002) Tumors and tumor like lesions of the testis: radiologic–pathologic correlation. Radiographics 22:189–216 (PMID: 11796908)
[15] Muglia V, Tucci S, Elias J, Trad CS, Bilbey J, Cooperberg PL. (2002) Magnetic resonance imaging of scrotal diseases: when it makes the difference. Urology 59:419–423 (PMID: 11880084)
Case information
| URL: | https://eurorad.org/case/12347 |
| DOI: | 10.1594/EURORAD/CASE.12347 |
| ISSN: | 1563-4086 |
Figure 1
Department of Diagnostic and Intervention Radiology. Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt.
Department of Diagnostic and Intervention Radiology. Kasr Al-Ainy Hospital, Cairo University. Cairo, Egypt.
Department of Diagnostic and Intervention Radiology. Kasr Al-Ainy Hospital. Cairo, Egypt.
Figure 3
Department of Diagnostic and Interventional Radiology, Cairo University, Kasr Al-Ainy Hospital, Cairo, Egypt.