Case Presentation: A 27-year-old Hispanic man with a history of hyperlipidemia and smoking (marijuana and tobacco) was initially seen by Urology for a right palpable testicular mass that enlarged over the past 2 months prior to presentation. Our patient denied a history of familial testicular cancer and a history of undescended testes. He reported no testicular pain or difficulty with urination or ejaculation. Scrotal ultrasound demonstrated multiple hypodense nodules scattered throughout both testicles and a dominant hypoechoic mass in the right testicle measuring 2.4 cm. Tumor markers (LDH, β-hCG, AFP) were negative. Given concerns for testicular carcinoma, the decision was made to pursue right orchiectomy. Pathology reports showed noncaseating granulomatous orchitis with no evidence of fungal or acid-fast organisms on staining. With the findings above, the patient established care in our primary care clinic. Patient reported no cardiopulmonary symptoms. A CT chest showed perilymphatic distribution of pulmonary micronodules likely representing pulmonary sarcoidosis, along with prominent hilar lymphadenopathy. Pulmonary function tests were normal. Calcium level collected at the visit was normal, while 25-hydroxyvitamin D was very low.Patient was seen by the Pulmonology team. He underwent a left lung biopsy showing noncaseating granulomatous inflammation. Due to the patient having pulmonary and extrapulmonary sarcoidosis, the decision was made to start the patient on oral prednisone.

Discussion: Sarcoidosis is a rare systemic disorder characterized by noncaseating granulomas that can present within a myriad of organs, most commonly in the lungs [1]. Testicular involvement is an exceptionally rare presentation of sarcoidosis, accounting for only 0.2% of cases diagnosed [2].Testicular sarcoidosis can be challenging to diagnose. Its presentation as a testicular mass with or without pain can mimic testicular cancer [3]. Furthermore, its peak onset is in the 2nd – 4th decade, which coincidentally is the same demographic that testicular cancer most commonly presents [1]. Although rare, there are multiple reports of testicular sarcoidosis that lead to inadvertent testicular removal, which happened in the case of our patient [3]. To avoid misdiagnosis and unnecessary surgical intervention, it is worthwhile to always suspect sarcoidosis, along with testicular cancer, as part of a differential for a patient that presents with a testicular mass.Distinguishing between testicular sarcoidosis and malignancy is challenging, but there are tools that can help ease the burden. All initial workups of testicular masses should include relevant serum tumor markers (AFP, β-hCG, LDH) [4]. In some instances, imaging modalities, such as scrotal ultrasonography, can differentiate between sarcoidosis and malignancy [5]. Finally, biopsy of extratesticular lesions that are discovered can assist with diagnosis [3].

Conclusions: Although a rare presentation in of itself, it is always important to consider testicular sarcoidosis in a patient with a newly diagnosed testicular mass. The appropriate workup should be attempted to rule out other causes of the mass prior to declaring it a tumor. Additionally, no clear guidelines are available regarding the workup of a patient with testicular sarcoidosis. More cases of patients with extra-pulmonary findings of sarcoidosis need to be discussed to help assess whether more workup needs to be done to find sarcoid involvement in other organs.

IMAGE 1: CT chest showing hilar lymphadenopathy

IMAGE 2: Non-caseating Granulomas seen in Testicular tissue