Images in Clinical Urology Segmental Testicular Infarction Due to Minocycline-induced Antineutrophil Cytoplasmic Antibodyepositive Vasculitis Timothy D. Lyon, Matthew C. Ferroni, Daniel P. Casella, Louis A. D’Agostino, and Stephen V. Jackman Segmental testicular infarction is an uncommon clinical entity marked by acute scrotal pain and swelling. Classically, these appear as wedge-shaped, avascular, hypoechoic lesions on a testicular ultrasound. We present a unique case of testicular infarct caused by an antineutrophil cytoplasmic antibodyepositive vasculitis secondary to the use of the antibiotic minocycline. The patient’s symptoms resolved with cessation of minocycline. We suggest that patients who present with otherwise unexplained testicular infarction undergo a careful review of medications to uncover a potential cause. UROLOGY -: -e-, 2014. 2014 Elsevier Inc.
Figure 1. In the acute setting, scrotal ultrasound shows hypoechoic intratesticular lesion with poorly defined borders. The inferior portion of the infarct is slightly more hyperechoic than the rest. RT, right; SAG, sagittal.
A
47-year-old man presented with right testicular pain and swelling associated with 1 month of fevers, night sweats, abdominal pain, myalgias, headache, and extremity numbness. History was significant for rosacea, for which he took daily antibiotics. These were changed from doxycycline to minocycline 12 months before presentation. Testicular ultrasound revealed an avascular hypoechoic intratesticular lesion (Fig. 1); 1 week later this had matured into a wedgeshaped infarct (Fig. 2). Serum was positive for antineutrophil cytoplasmic antibody, and testis tumor Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA Reprint requests: Timothy D. Lyon, M.D., Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA 15213. E-mail: [email protected] Submitted: January 12, 2014, accepted (with revisions): March 10, 2014
ª 2014 Elsevier Inc. All Rights Reserved
Figure 2. Follow-up ultrasound after 1 week reveals interval development of a more homogenous and well-defined infarct. Doppler signal confirms the absence of intralesional blood flow. Note the evolution into a more defined wedge shape, corresponding to the structure of the affected vascular arcade. RT, right; TRV, transverse.
markers were negative. He was diagnosed with minocycline-induced vasculitis, and his symptoms resolved with cessation of minocycline. Testicular infarction is a rare cause of acute scrotal pain.1-4 Ultrasonographic appearance is classically wedgeshaped and initially heterogeneous, owing to intralesional edema and hemorrhage, and becomes more homogeneously hypoechoic as the infarct ages.5 A high degree of suspicion is needed to avoid the misdiagnosis of an intratesticular mass leading to unnecessary orchiectomy. Care is supportive.1,2 Minocycline is known to induce a variety of autoimmune conditions including vasculitis.6,7 One case to our knowledge describes a biopsy-proven testicular infarct due to a minocycline-induced antineutrophil cytoplasmic 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2014.03.011
e1
antibodyepositive vasculitis.6 A drug-induced vasculitis should remain on the differential for patients who present with an otherwise unexplained testicular infarct. References 1. Madaan S, Joniau S, Klockaerts K, et al. Segmental testicular infarction: conservative management is feasible and safe. Eur Urol. 2008;53:441-445. 2. Madaan S, Joniau S, Klockaerts K, et al. Segmental testicular infarction. Conservative management is feasible and safe: part 2. Eur Urol. 2008;53:656-658.
e2
3. Magill P, Jacob T, Lennon GM. A rare case of segmental testicular infarction. Urology. 2007;69:e987-e988. 4. Ruibal M, Quintana JL, Fernandez G, et al. Segmental testicular infarction. J Urol. 2003;170:187-188. 5. Aquino M, Nghiem H, Jafri SZ, et al. Segmental testicular infarction: sonographic findings and pathologic correlation. J Ultrasound Med. 2013;32:365-372. 6. Lenert P, Icardi M, Dahmoush L. ANA (þ) ANCA (þ) systemic vasculitis associated with the use of minocycline: case-based review. Clin Rheumatol. 2013;32:1099-1106. 7. Katada Y, Harada Y, Azuma N, et al. Minocycline-induced vasculitis fulfilling the criteria of polyarteritis nodosa. Mod Rheumatol. 2006;16: 256-259.
UROLOGY
-
(-), 2014
Figure 1. In the acute setting, scrotal ultrasound shows hypoechoic intratesticular lesion with poorly defined borders. The inferior portion of the infarct is slightly more hyperechoic than the rest. RT, right; SAG, sagittal.
A
47-year-old man presented with right testicular pain and swelling associated with 1 month of fevers, night sweats, abdominal pain, myalgias, headache, and extremity numbness. History was significant for rosacea, for which he took daily antibiotics. These were changed from doxycycline to minocycline 12 months before presentation. Testicular ultrasound revealed an avascular hypoechoic intratesticular lesion (Fig. 1); 1 week later this had matured into a wedgeshaped infarct (Fig. 2). Serum was positive for antineutrophil cytoplasmic antibody, and testis tumor Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA Reprint requests: Timothy D. Lyon, M.D., Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA 15213. E-mail: [email protected] Submitted: January 12, 2014, accepted (with revisions): March 10, 2014
ª 2014 Elsevier Inc. All Rights Reserved
Figure 2. Follow-up ultrasound after 1 week reveals interval development of a more homogenous and well-defined infarct. Doppler signal confirms the absence of intralesional blood flow. Note the evolution into a more defined wedge shape, corresponding to the structure of the affected vascular arcade. RT, right; TRV, transverse.
markers were negative. He was diagnosed with minocycline-induced vasculitis, and his symptoms resolved with cessation of minocycline. Testicular infarction is a rare cause of acute scrotal pain.1-4 Ultrasonographic appearance is classically wedgeshaped and initially heterogeneous, owing to intralesional edema and hemorrhage, and becomes more homogeneously hypoechoic as the infarct ages.5 A high degree of suspicion is needed to avoid the misdiagnosis of an intratesticular mass leading to unnecessary orchiectomy. Care is supportive.1,2 Minocycline is known to induce a variety of autoimmune conditions including vasculitis.6,7 One case to our knowledge describes a biopsy-proven testicular infarct due to a minocycline-induced antineutrophil cytoplasmic 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2014.03.011
e1
antibodyepositive vasculitis.6 A drug-induced vasculitis should remain on the differential for patients who present with an otherwise unexplained testicular infarct. References 1. Madaan S, Joniau S, Klockaerts K, et al. Segmental testicular infarction: conservative management is feasible and safe. Eur Urol. 2008;53:441-445. 2. Madaan S, Joniau S, Klockaerts K, et al. Segmental testicular infarction. Conservative management is feasible and safe: part 2. Eur Urol. 2008;53:656-658.
e2
3. Magill P, Jacob T, Lennon GM. A rare case of segmental testicular infarction. Urology. 2007;69:e987-e988. 4. Ruibal M, Quintana JL, Fernandez G, et al. Segmental testicular infarction. J Urol. 2003;170:187-188. 5. Aquino M, Nghiem H, Jafri SZ, et al. Segmental testicular infarction: sonographic findings and pathologic correlation. J Ultrasound Med. 2013;32:365-372. 6. Lenert P, Icardi M, Dahmoush L. ANA (þ) ANCA (þ) systemic vasculitis associated with the use of minocycline: case-based review. Clin Rheumatol. 2013;32:1099-1106. 7. Katada Y, Harada Y, Azuma N, et al. Minocycline-induced vasculitis fulfilling the criteria of polyarteritis nodosa. Mod Rheumatol. 2006;16: 256-259.
UROLOGY
-
(-), 2014
