WPD

Iraas1

Aotco

nrgg

FCC

vU1

Fe

©A

Images in Clinical Urology

egener Granulomatosisresenting as Epididymitis

. Chris Miller and Michael N. Koss

solated epididymitis is a very rare presentation of Wegener granulomatosis (WG). Only 1 such case has been previouslyeported. We report a case of epididymitis in which WG was not suspected clinically or pathologically at orchiectomy,nd the patient subsequently developed pulmonary involvement with WG. WG was ultimately diagnosed and treatedfter lung biopsy several months after the orchiectomy. The retrospective pathologic review of the orchiectomypecimen confirmed the presence of WG in the epididymis; the testicular tissue was not involved. UROLOGY 73:

225–1226, 2009. © 2009 Elsevier Inc.

Fltrate; large arrow, a granuloma.

Flv

47-year-old man was evaluated for cough andfever. Four months earlier, he had developedright testicular pain and swelling. After 2 weeks

f ciprofloxacin, he had undergone right radical orchiec-omy. Weeks after the procedure he developed fever,ough, weight loss, and fatigue. Several more weeks ofral antibiotics were ineffective.A chest computed tomography scan showed bilateral

ecrotizing pulmonary masses (Fig. 1). Right lung biopsyevealed focal vasculitis and necrotizing and suppurativeranulomatous pneumonitis consistent with Wegenerranulomatosis (WG). The results of the fungal, acid fast,

rom the Departments of Infectious Disease and Pathology, University of Southernalifornia Keck School of Medicine, Los Angeles County � University of Southernalifornia Medical Center, Los Angeles, CaliforniaReprint requests: D. Chris Miller, M.D., Department of Infectious Disease, Uni-

ersity of Southern California Keck School of Medicine, Los Angeles County �niversity of Southern California Medical Center, General Hospital, Room 6620,

igure 1. Chest computed tomography scan showing bilat-ral pulmonary masses.

200 North State Street, Los Angeles, CA 90033. E-mail: chrismil66@hotmail.comSubmitted: January 9, 2009, accepted (with revisions): February 4, 2009

s

2009 Elsevier Inc.ll Rights Reserved

igure 2. Suppurative (neutrophil-rich) necrotizing granu-oma in epididymis. Small arrow indicates neutrophilic infil-

igure 3. High-magnification view of granulomatous vascu-itis in epididymis. Small black arrows indicate outline ofessel wall. Note, infiltrate within vessel wall. Giant cell

een at right (white arrow).

0090-4295/09/$34.00 1225doi:10.1016/j.urology.2009.02.015

apcsvgs

bpnep

eco

tm

R1

2

1

nd Gram stains were negative. The diagnosis was sup-orted by elevated cytoplasmic-staining anti-neutrophilytoplasmic antibodies (anti-proteinase-3). Pathologylides from the patient’s orchiectomy specimen were re-iewed (Figs. 2 and 3). The histologic appearance of theranulomatous inflammation in the epididymis was con-istent with WG. The testicular tissue was not involved.

WG limited to the epididymis is rare. Only 1 case haseen previously reported.1 The diagnosis was made byathologic examination at orchiectomy (negative for anti-eutrophil cytoplasmic antibodies). The patient experi-nced recurrence after orchiectomy. Another study2 re-

orted a patient who presented with WG in the testis and

226

pididymis simultaneously (negative for anti-neutrophilytoplasmic antibodies); the patient responded well torchiectomy alone.WG should be considered in patients with granuloma-

ous lesions in the epididymis. Follow-up is required toonitor for recurrence.

eferences. Al-Arfaj A. Case report: limited Wegener’s granulomatosis of the

epididymis. Int J Urol. 2001;8:333-335.. Lee SS, Tang SH, Sun GH, et al. Case report: limited Wegener’s

granulomatosis of the epididymis and testis. Asian J Androl. 2006;8:

737-739.

UROLOGY 73 (6), 2009