EP18 Testicular sarcoidosis: a challenging diagnosis

Abstract Case report - Introduction Sarcoidosis is an inflammatory systemic disorder that is characterised by the formation of immune granulomas. Lung involvement is seen in about 90% of patients but extrapulmonary sarcoidosis can be a clinically challenging manifestation. Despite the majority remitting in three years, a considerable proportion (10-30%) develop chronic disease requiring continuous treatment. The development of extrapulmonary disease can be prior to, after or concomitant with pulmonary disease. Although cardiac, ophthalmic, neurological, and musculoskeletal manifestations have been described elsewhere, testicular involvement remains a rare phenotype of the disease which is poorly understood. Case report - Case description A 36-year old male patient born in Jamaica, presented in 2017 with unilateral left-sided testicular pain and enlargement measuring 20 x 16 x 18mm on ultrasound. This was initially suspected of malignancy or an atypical infection. A subsequent CT chest, abdomen and pelvis demonstrated nodal evidence of hilar, internal mammary and mediastinum involvement. Blood tests were unremarkable other than a raised lactate dehydrogenase (248 IU. mL (NR < 240)), low testosterone (5.2nmol/L (NR 10-30)) and androgen index (11.6 (NR 25-90). The patient underwent an orchidectomy and prosthesis, histological sampling demonstrated idiopathic granulomatous orchitis with features consistent of sarcoidosis. Malignancy could be excluded, and the absence of characteristic histochemical staining patterns favoured sarcoid to other differential diagnoses. He was efficaciously treated after a year’s interval with prednisolone, which was gradually weaned from 40mg. However, eighteen months later, the patient returned complaining of right testicular pain. Ultrasound showed inflammation and enlargement of the testicle. PET-CT supported a recurrence of testicular involvement along with systemic disease involvement including neuropathy. His serum angiotensin-converting enzyme was raised at 118 IU/L (NR8-52) and responded similarly to high dose corticosteroid treatment. Additionally, an MRI brain showed neurosarcoid in the superior sagittal sinus tracking along the right transverse sinus. Currently the patient is maintained on subcutaneous methotrexate 25mg disease modifying anti-rheumatic drug (DMARD) monotherapy. He has diabetes attributed to prolonged corticosteroid use over the last three years. As a result of his testicular involvement, the patient suffers from erectile dysfunction and hypogonadism with low testosterone production. Chronic pain and neuro-sagittal involvement have contributed to difficulties in achieving treatment targets with increased malaise, fatigue and poor cognition all compounding his disease further. This has posed a challenge as to whether this is due to the disease or the patients use of cannabis or a combination of the two. Case report - Discussion Testicular sarcoid is a rare presentation in which only around 0.2% of all sarcoidosis cases are diagnosed. The epididymis, vas deferens and testis can all be involved. Presentation can mimic that of infections such as tuberculosis mycobacterium and malignancy with uni- or bilateral testicular involvement. Challenges arise, as in this case, when the patient presents with genito-urinary involvement in the absence of more systemic features which may favour extra-pulmonary manifestations. The diagnosis and treatment can be difficult, as corticosteroid response tends to be most effective at high doses and disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate have evidence for pulmonary and extra-pulmonary sites. Our patient developed more systemic features at a later stage. The diagnosis was challenging and there was an interval of a year between the orchidectomy and commencement of steroids. This shows the ongoing difficulties in diagnosing patients with sarcoidosis and the delays that occur in treatment initiation. Testicular involvement has created debilitating symptoms for the patient with chronic pain affecting his ability to sit and ride his bike for extended periods. Involvement of the other testicle, ongoing low testosterone production and erectile dysfunction have posed difficult discussions around future fertility. It is encouraging that he has managed to wean from corticosteroid and methotrexate seems to be controlling the disease quite well. The evidence relating to best possible DMARD treatment in testicular sarcoid is still scarce and is an interesting point of discussion. There have been co-existent reports of testicular tumours in sarcoid, and as most of these patients are seen by surgical specialties, further work must heighten awareness of sarcoid in this cohort of patients. Case report - Key learning points We feel this is an unusual presentation of sarcoidosis; a patient who presented with primary testicular involvement and is pertinent to the topic of extrapulmonary disease manifestation. Despite appropriate treatment, he developed recurrence within the other testis two years later. Testicular involvement as a manifestation of extra-pulmonary sarcoidosis is rare and difficult to treat. There are limitations in treatment beyond corticosteroid, although DMARD therapy with methotrexate being favoured in case reports listed elsewhere. It is difficult to differentiate from malignancy and infection, and as a result often requires complete removal of the testis for histological interpretation. This can lead to hypogonadism and may affect long-term fertility which has significant psychosocial impacts for patients. There is an association between sarcoidosis and the development of co-morbidities which carries significant long-term complications. The relationship between long-term corticosteroid use and ethnicity in the development of co-morbidities in patients with sarcoidosis is poorly understood. Medical and surgical specialties that manage most cases involving testicular masses may not be aware of the differentials such as sarcoid; clinicians may therefore be exposed to a degree of cognitive bias in these cases. We propose this as an example to improve framing of similar cases for clinicians in the future. From a patient’s perspective, similar cases require careful discussion to explore potential management options and their outcomes as the impact may be life changing.


EXTRA-
Case report -Introduction: Sarcoidosis is an autoimmune, multi-system condition in which the formation of non-caseating, granulomas is a key histological feature. Clinical presentation can be variable and may lead to a delay in recognition. Most cases will resolve with minimal or no intervention. Awareness of the condition and features helps guide longterm management and as illustrated in cases below, rheumatologists may often be involved in helping diagnose and coordinate the patient pathway. Case report -Case description: A 51-year old female ex-smoker experienced 6 months of fatigue, dry cough, mild exertional dyspnoea, sweats, mild weight loss and arthralgia after a cholecystectomy. She described lesions typical of erythema nodosum coinciding with a raised CRP (58g/L) which later normalised. Other than an elevated serum ACE (71 U/L), rest of testswere normal. Plain chest radiograph was normal but a co-incidental CT abdomen for non-specific abdominal discomfort showed small volume abdominal lymphadenopathy. Further imaging showed bilateral mediastinal and hilar lymphadenopathy. Pulmonary function tests and joint ultrasound were normal. EBUS sampling (August 2014) excluded malignancy but confirmed sarcoid granulomas. She briefly required non-steroidals for arthralgia. Four years later, she is still well with resolution of lymphadenopathy. A 41-year old male non-smoker presented with 6 weeks of bilateral heel pain followed by myalgia, weight loss, headaches, sweats, intermittent blurred vision, and a non-specific neck rash. He was afebrile with normal urinalysis, CRPs 24-39 mg/L, CCP, ANCA, ANA negative, (Serum ACE sample insufficient). Infection screening (including TB) was negative. Slit lamp examination was normal. Trans-bronchial sampling of hilar lymphadenopathy seen on imaging excluded lymphoma but showed granulomas typical of sarcoidosis. The patient fully recovered within a few months without medication or recurrence. A 63-year-old female was referred with ankle pain and swelling after 5 months of erythematous leg swelling treated initially as cellulitis. She also had bilateral, intermittent leg cramps and recent intermediate uveitis. She was positive for HLA B27 and ANA (homogenous speckled pattern) with a raised serum ACE (98 U). ANCA was negative, creatinine kinase normal. Background included treated squamous cell carcinoma and degenerative disc disease. Ankle problems had resolved when seen possibly due to prednisolone for uveitis. EBUS samplingof bilateral hilarlymphadenopathyconfirmedsarcoid histology. Since commencing azathioprine (50mg) for recurrent uveitis, shestayswell. Case report -Discussion: Sarcoidosis is a granulomatous systemic disease thought to be Th-1 mediated but pathogenesis remains unclear. Heterogeneity in presentation and organ involvement may lead to delays or missed diagnoses. Like these cases, patients may have one or more presentations to variousmedical specialities before alink is made. Careful note of antecedent history, current symptoms and examination findings can point towards a differential of sarcoid particularly if bilateral ankle involvement or typical skin lesions are present. Erythema nodosum can occur which the first case had described. Given the smoking and weight loss history, the differential of malignancy had to be excluded first. Sarcoid arthropathy, as seen in these cases, typically presents as arthralgia, myalgia, or arthritis in either acute or chronic form. Sometimes myopathy and bone involvement are seen though erosive disease is uncommon. Cases often have minimal or no respiratory symptoms but chest imaging can pick up features including bilateral hilar lymphadenopathy (more than 75% of cases) and less commonly pulmonary parenchymal changes (nodules, groundglass changes, fibrosis) orpleural effusions. Most cases will resolve over time with minimal intervention as in the first two cases. Some require non-steroidal anti-inflammatories. Steroids may be required if there are more inflammatory features affecting joints or other organs. Disease modifying therapies (biologic and non-biologic) have been usedin more chronicor resistant cases. Sarcoid may co-exist with or mimic other conditions. In the last case, the unifying diagnosis of uveitis, skin changes and joint involvement seems to be sarcoid. However, it was interesting that the patient had mixed serology and showed some features of a seronegative arthritis profile as spondyloarthritis and sacroiliitis have been reportedwith sarcoidosis.
Rheumatologists are often familiar with features of the condition. Thus, they can help link symptoms to guide appropriate investigations and further management with good outcomes. Case report -Key learningpoints . Sarcoidosis can have a heterogeneous presentation so may take a while for diagnosis to be made . Respiratory symptoms may not be present despite findings on chest imaging . Rheumatologists are often involved in diagnosis and treatment when patients with sarcoid related arthralgia or arthritis type symptoms get referred . Most cases will resolve with minimal intervention . Early recognition can streamline investigations and management subsequently improving the patient journey . In cases with a mixed autoantibody profile, there may be a discussion on whether one or more conditions are present to explain all the features

EP18 TESTICULAR SARCOIDOSIS: A CHALLENGING DIAGNOSIS
Vishit Patel 1 , Sanketh Rampes 1 , Deepak Nagra 2 , Benjamin Clarke 2 and James Galloway 2 Case report -Introduction: Sarcoidosis is an inflammatory systemic disorder that is characterised by the formation of immune granulomas. Lung involvement is seen in about 90% of patients but extrapulmonary sarcoidosis can be a clinically challenging manifestation. Despite the majority remitting in three years, a considerable proportion (10-30%) develop chronic disease requiring continuous treatment. The development of extrapulmonary disease can be prior to, after or concomitant with pulmonary disease. Although cardiac, ophthalmic, neurological, and musculoskeletal manifestations have been described elsewhere, testicular involvement remains a rare phenotype of the disease which is poorly understood.
Case report -Case description: A 36-year old male patient born in Jamaica, presented in 2017 with unilateral left-sided testicular pain and enlargement measuring 20 x 16 x 18mm on ultrasound. This was initially suspected of malignancy or an atypical infection. A subsequent CT chest, abdomen and pelvis demonstrated nodal evidence of hilar, internal mammary and mediastinum involvement. Blood tests were unremarkable other than a raised lactate dehydrogenase (248 IU. mL (NR < 240)), low testosterone (5.2nmol/L (NR 10-30)) and androgen index (11.6 (NR 25-90). The patient underwent an orchidectomy and prosthesis, histological sampling demonstrated idiopathic granulomatous orchitis with features consistent of sarcoidosis. Malignancy could be excluded, and the absence of characteristic histochemical staining patterns favoured sarcoid to other differential diagnoses. He was efficaciously treated after a year's interval with prednisolone, which was gradually weaned from 40mg. However, eighteen months later, the patient returned complaining of right testicular pain. Ultrasound showed inflammation and enlargement of the testicle. PET-CT supported a recurrence of testicular involvement along with systemic disease involvement including neuropathy. His serum angiotensin-converting enzyme was raised at 118 IU/L (NR8-52) and responded similarly to high dose corticosteroid treatment. Additionally, an MRI brain showed neurosarcoid in the superior sagittal sinus tracking along the right transverse sinus. Currently the patient is maintained on subcutaneous methotrexate 25mg disease modifying anti-rheumatic drug (DMARD) monotherapy. He has diabetes attributed to prolonged corticosteroid use over the last three years. As a result of his testicular involvement, the patient suffers from erectile dysfunction and hypogonadism with low testosterone production. Chronic pain and neuro-sagittal involvement have contributed to difficulties in achieving treatment targets with increased malaise, fatigue and poor cognition all compounding his disease further. This has posed a challenge as to whether this is due to the disease or the patients use of cannabisor acombinationof the two. Case report -Discussion: Testicular sarcoid is a rare presentation in which only around 0.2% of all sarcoidosis cases are diagnosed. The epididymis, vas deferens and testis can all be involved. Presentation can mimic that of infections such as tuberculosis mycobacterium and malignancy with uni-or bilateral testicular involvement. Challenges arise, as in this case, when the patient presents with genito-urinary involvement in the absence of more systemic features which may favour extra-pulmonary manifestations. The diagnosis and treatment can be difficult, as corticosteroid response tends to be most effective at high doses and disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate have evidence for pulmonary and extra-pulmonary sites. Our patient developed more systemic features at a later stage. The diagnosis was challenging and there was an interval of a year between the orchidectomy and commencement of steroids. This shows the ongoing difficulties in diagnosing patients with sarcoidosis and the delays that occur in treatment initiation. Testicular involvement has created debilitating symptoms for the patient with chronic pain affecting his ability to sit and ride his bike for extended periods. Involvement of the other testicle, ongoing low testosterone production and erectile dysfunction have posed difficult discussions around future fertility. It is encouraging that he has managed to wean from corticosteroid and methotrexate seems to be controlling the disease quite well. The evidence relating to best possible DMARD treatment in testicular sarcoid is still scarce and is an interesting point of discussion. There have been co-existent reports of testicular tumours in sarcoid, and as most of these patients are seen by surgical specialties, further work must heighten awareness of sarcoid in this cohort of patients.
Case report -Key learning points: We feel this is an unusual presentation of sarcoidosis; a patient who presented with primary testicular involvement and is pertinent to the topic of extrapulmonary disease manifestation. Despite appropriate treatment, he developed recurrence within the other testis two years later. Testicular involvement as a manifestation of extra-pulmonary sarcoidosis is rare and difficult to treat. There are limitations in treatment beyond corticosteroid, although DMARD therapy with methotrexate being favoured in case reports listed elsewhere. It is difficult to differentiate from malignancy andinfection,andasaresultoftenrequirescomplete removal of the testis forhistological interpretation. This can lead to hypogonadism and may affect long-term fertility which has significant psychosocial impacts for patients. There is an association between sarcoidosis and the development of co-morbidities which carries significant long-term complications. The relationship between longterm corticosteroid use and ethnicity in the development of co-morbidities in patients with sarcoidosis is poorly understood. Medical and surgical specialties that manage most cases involving testicular masses may not be aware of the differentials such as sarcoid; clinicians may therefore be exposed to a degree of cognitive bias in these cases. We propose this as an example to improve framing of similar cases for clinicians in the future. From a patient's perspective, similar cases require careful discussion to explore potential management options and their outcomes as the impact maybe life changing.