Sarcoidosis mimicking disseminated testicular cancer.

Abstract: Sarcoidosis rarely involves the genitourinary system or the spinal cord. This report describes a case of sarcoidosis with a scrotal mass, a mass compressing the spinal cord, and lesions in the liver and spleen. This case illustrates an uncommon manifestation of sarcoidosis, which may mimic disseminated testicular cancer.

Key Words: genitourinary sarcoidosis, neurosarcoidosis, sarcoidosis, spinal cord sarcoidosis

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Sarcoidosis is a chronic multisystem disease characterized by noncaseating granulomas, commonly involving the lungs (90%), skin (25%), and eyes (25%). (1) Involvement of the genitourinary system or spinal cord occurs in fewer than 1% of patients with sarcoidosis. (1,2) Therefore, concurrent involvement of the genitourinary system and spinal cord would be rare. We report a case of sarcoidosis involving the epididymis, spinal cord, liver, and spleen.

Case Report

A 30-year-old black male presented with a painful left testicular mass and worsening weakness in his lower extremities for 2 weeks. He reported no history of trauma. He had no fever, dyspnea, cough, night sweats, or bowel or bladder incontinence. He reported a 30-pound weight loss over the previous 6 months. He was unemployed and did not abuse tobacco, alcohol, or illicit drugs. Four years before this admission, the patient had been incarcerated for 1 year. Physical examination revealed normal motor strength in upper extremities and reduced strength in lower extremities. Ankle and knee reflexes were absent, and Babinski sign was positive in both lower extremities. A sensory level was noted at T10, and crude touch, fine touch, proprioception, and vibration sensations were reduced below this level. The rectal tone was normal. There was a 2 X 2 cm nontranslucent, hard, and tender mass just above the left testis. Lymph nodes were not palpated in the cervical, supraclavicular, axillary, or inguinal regions, and hepatosplenomegaly was absent. Complete blood count, serum electrolytes, and liver functions were normal. The [beta]-human chorionic gonadotropin level was 7 IU/L (reference, <10 IU/L). HIV serology and tuberculin skin tests were negative. Urine histoplasma antigen was negative. The chest radiograph demonstrated normal cardiac silhouette, lung fields, and mediastinum. A scrotal ultrasound showed a solid mass in the left epididymis measuring 2.4 X 2.1 X 2.3 cm. The testes were normal in size and appearance. Magnetic resonance imaging (MRI) of the spine revealed an intradural, extramedullary, 16-mm enhancing mass in the left half of the bony canal at the T10 to T11 level. The mass compressed the spinal cord and caused mild spinal cord edema (Fig. 1A). MRI of the head was normal. The computed tomography scan of the chest and abdomen showed hilar and mediastinal lymphadenopathy in the chest, left iliac lymphadenopathy, and scattered small hypodense lesions in the liver and spleen (Fig. 2). Pulmonary function test revealed FEV[.sub.1] of 2.75 L (82% of predicted), FVC of 4.29 L (103% of predicted), FEV[.sub.1]/FVC ratio of 64%, total lung capacity of 4.29 L (103% predicted), and diffusing capacity of 21.6 mL/mmHg/min (69% of predicted).

The patient received high-dose dexamethasone with significant improvement of the paraplegia. He underwent left orchiectomy for tissue diagnosis. The biopsy showed extensive noncaseating granulomas in the epididymis and testis. Special stains for acid-fast, Gomori methenamine silver, and periodic acid-fast were negative, and malignant cells were not identified. Subsequently, a bronchoscopy with transbronchial biopsy was performed, and noncaseating granulomas with multiple multinucleated giant cells were noted in the biopsy. Again, neither fungus nor mycobacteria were identified with special stains or culture. A diagnosis of sarcoid was made based on these results. Dexamethasone was switched to oral prednisone, and the patient was discharged home. Two months after discharge, the patient had no lower extremity weakness, and his neurologic examination was normal. A repeat MRI of the spine showed reduction in the size of the mass in the spinal cord (Fig. 1B).

Discussion

The differential diagnoses of this case included testicular cancer, lymphoma, sarcoidosis, tuberculosis, and fungal infection. The results of tissue biopsies from two different sites and a clinical response to corticosteroids support the diagnosis of sarcoidosis. To our knowledge, this is the first case of sarcoidosis presenting with concurrent involvement of the genitourinary system and spinal cord.

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Genitourinary sarcoidosis (GUS) is rare and occurs in 0.2% of clinical cases and 5% of those undergoing autopsy. (3) Approximately 60 cases of male GUS have been reported. (4) GUS presents with a unilateral, nodular, painless scrotal mass in young males. (5) Testicular involvement is uncommon in GUS and occurs only in 21% of those patients. (5) Neurosarcoidosis occurs in 5% of patients with sarcoidosis, and spinal cord involvement occurs in fewer than 10% of these patients. (2) MRI findings, as in our case, are not specific. Although therapy for GUS and neurosarcoidosis is controversial, our patient did improve with corticosteroid therapy.

Conclusion

Sarcoidosis should be considered in the differential diagnosis in patients with spinal cord and genitourinary masses in the appropriate epidemiologic setting.

References

1. Rieger J, Hosten N. Spinal cord sarcoidosis. Neuroradiology 1994;36:627-628.

2. Hamasaki T, Noda M, Kamei N, et al. Intradural extramedullary mass formation in spinal cord sarcoidosis: case report and literature review. Spine 2003;28:E420-E423.

3. Hurd DS, Olsen T. Cutaneous sarcoidosis presenting as a testicular mass. Cutis 2000;66:435-438.

4. Kodama K, Hasegawa T, Egawa M, et al. Bilateral epididymal sarcoidosis presenting without radiographic evidence of intrathoracic lesion: review of sarcoidosis involving the male reproductive tract. Int J Urol 2004;11:345-348.

5. Ryan DM, Lesser BA, Crumley LA, et al. Epididymal sarcoidosis. J Urol 1993;149:134-136.

Ibrahim SultanAli, MD, Muhammad Zaman, MD, and Sachin Yende, MD, MS

From the Division of Pulmonary and Critical Care Medicine, The University of Tennessee Health Science Center, Memphis, TN.

Reprint requests to Dr. Ibrahim SultanAli, 956 Court Ave., Coleman College of Medicine, H314, Memphis, TN 38164. Email: [e-mail]

Accepted January 13, 2005.

RELATED ARTICLE: Key Points

* Sarcoidosis involves virtually every organ, although lung and lymph node involvements are most common.

* The involvement of the genitourinary system or the nervous system, particularly the spinal cord, is uncommon.

* Sarcoidosis presenting as a testicular and spinal cord mass mimics testicular cancer with metastases and should be considered in the differential diagnosis in the appropriate epidemiologic setting.