Teaching Case

52-year-old man with clinical history of asthma who goes to emergency room with 9 hours onset of right testicular pain. A testicular ultrasound was requested.

Testicular asymmetry with enlargement of the right testicle. An intraparenchymal lesion of 2,6 x 1,5 x 2 cm (AP x T x CC) was identified in the right testicle, with lobed contours, heterogenous echogenicity, and no evident vascularization in Doppler mode. These findings suggested a right intratesticular tumour as the first possibility. Given the image findings and the absence of known predisposing factors of ischemic events, an orchiectomy was performed.

Segmental infarct of testicle is a rare clinical entity in which, secondary to an ischemic process, a heterogeneous lesion is formed in the testicular parenchyma [1].

Testicular infarction usually has an idiopathic aetiology, but it can be related to predisposing factors such as trauma, infection, hypercoagulability disorders, torsion, iatrogenic vascular injury, or, as in this case, vasculitis [1,2].

The clinical presentation is acute testicular pain, but it also can appear as a palpable mass [2].

Main tool for diagnosis is B mode and Doppler mode ultrasound, being important to compare with the other testicle. Image findings include focal hypoechoic wedge-shaped or rounded region in the testis, absence of colour Doppler flow in the hypoechoic region, and a slight retraction of the tunica albuginea adjacent [3].

Ultrasound imaging does not differentiate well between a tumour, haematoma and an infarct. Tumours can have high vascularization, and testicular haematoma and testicular infarct have very low or no vascularization; however, differentiation of segmental testicular infarction from a small intratesticular tumour, which may have a low flow, is difficult [4].

Diagnosis may be aided by MRI. The infarct area appears as a well-defined lesion, isointense in T1WI and can show hyperintense foci of haemorrhage; T2 WI shows a hypointense area surrounded by a complete hypointense rim. In post-contrast T1WI, one of the most relevant characteristics is the presence of a surrounding markedly enhanced rim [3].

In patients with negative tumour markers, unless symptoms dictate otherwise, a conservative approach can be taken and surgery avoided. Short-term ultrasound follow-up is recommended in two or four weeks; after this time, haematomas typically decrease in size and infarct areas become avascular and more hypoechoic over time. In cases of uncertainty, such as this one, the diagnosis is made following orchiectomy [1].

After histological analysis and diagnosis of testicular infarction of vasculitic origin, a rheumatological study was performed to the patient, and diagnosis of eosinophilic granulomatosis with polyangiitis was made.

All patient data have been completely anonymised throughout the entire manuscript and related files.