Tertiary Syphilitic Gumma Mimicking Testicular Neoplasms

Abstract

Palpable testicular masses in men aged 20 to 50 years usually represent testicular germ cell tumors. Diagnostic work-up involves ultrasound examination as well as serum tumor markers alpha fetoprotein, beta-human chorionic gonadotropin and lactate dehydrogenase, and particularly the novel marker M371. Orchidectomy is mandatory for germ cell tumors. We report the rare case of testicular involvement by tertiary syphilis mimicking testicular neoplasms with testis-sparing management. A 46-year-old Caucasian male presented with a painless firm mass in the right testicle and multiple cutaneous plaques at the skin of the scrotum, penis and right forearm. Testicular serum tumor markers were negative. Syphilis Rapid Plasma Reagin test and Treponema pallidum immunoglobulin antibodies tests were positive. Radiological examination revealed bilateral testicular lesions as well as bipulmonal pleural-based opacities. Conservative management was attempted and treatment with ceftriaxone (2 g/day) intravenously for 14 days was administered. The testicular findings improved rapidly and significantly during antibiotic treatment. Radiological follow-up examinations after two weeks and two months showed further regression of the testicular and pulmonary lesions. This case represents an extremely rare testicular manifestation of tertiary syphilis. Due to rising syphilis incidence in Europe, tertiary syphilis with formation of gumma should be a differential diagnosis of testicular tumor. Thus, syphilis-specific treatment is safe and orchidectomy can be avoided.

Keywords: bilateral testicular masses; germ-cell tumor; gumma; orchidectomy; tertiary syphilis; testis-sparing management; treponema pallidum.

Figure 1. Cutaneous lesions

Multiple cutaneous lesions of the scrotum (A), penis (B) and right forearm (C)

Figure 2. Scrotal sonography at hospitalization

Right testis with hypoechogenic mass (up to 30 mm in diameter) in the middle third and smaller hypoechogenic lesion at the lower pole

Figure 3. T2-weighted MRI of the pelvis at hospitalization

Transversal view showing right testicular lesions with central hyperintensity and peripheral hypointensity. The right epididymis shows tubular dilatation with central hyperintensity and peripheral hypointensity

Figure 4. CT scan of the chest at hospitalization

Transversal image showing labeled bipulmonal pleural-based opacities with the largest lesion up to 21 mm in diameter

Figure 5. T2-weighted MRI of the pelvis at two-month follow up

Transversal image showing significant reduction of both number and size of testicular lesions

Figure 6. CT scan of the chest at two-month follow up

Transversal image showing significant labeled regression of the lesions with the largest lesion up to 6.9 mm in diameter