Corticosteroid Therapy Improves the Outcome of Semen Analysis in an Oligozoospermic Patient With Epididymal Sarcoidosis
We report on the case of a 25-year-old Caucasian man who presented to the outpatient clinic complaining of right scrotal stiffness for 1 year and new left scrotal pain and tenderness. He had been diagnosed with sarcoidosis by a mediastinal lymph node biopsy owing to a hilar lymphadenopathy 2 years previously after presenting with an acute onset and progressive course of fatigue and cough. The physical examination revealed multiple, painless subcutaneous nodules on his arms and upper thighs in addition to large, bilateral epididymal masses. The consistency and size of the testes were normal and there were no signs of varicocele on the physical examination. Laboratory investigations revealed a normal blood sugar concentration and normal liver and kidney functions with a slightly elevated erythrocyte sedimentation rate (14 mm/h). Moreover, serum α-fetoprotein and β-human chorionic gonadotropin were within the normal range. The urine was negative for acid-fast bacilli by Ziehl-Neelsen stain, which was repeated three times. Biochemical analysis revealed normal serum testosterone (15.85 nmol/L; normal range, 10.07 to 38.76 nmol/L) and luteinizing hormone levels (3 IU/L; normal range, 0.9 to 7.0 IU/L) and elevated serum follicle-stimulating hormone levels (15.4 IU/L; normal range, 1.5 to 12.4 IU/L). Semen analysis showed severe oligospermia (2×106/mL, ).\nT1-weighted post-contrast magnetic resonance imaging (MRI) revealed an enlarged and enhanced epididymis on both sides (). The sizes of the lesions in the right and left epididymis were 3.1 cm and 1.3 cm, respectively.\nThe patient underwent inguinal exploration to differentiate the scrotal malignancy. Exploration revealed enlargement of both epididymides with increased bilateral vascularity and firm consistency of the mass. The masses extended from the epididymis through the testis with thick adherent coverings. Incision of the tunica albuginea demonstrated normal seminiferous tubules with no mass in the testis. A biopsy sample was obtained from the epididymal mass for frozen section analysis. The sample revealed multiple noncaseating epithelioid granulomas (). Because the patient had been diagnosed with pulmonary sarcoidosis 2 years ago, malignancy of the testis and epididymis was ruled out easily and medical treatment considered.\nThe patient was given 40 mg of prednisone/d for 1.5 months. Subsequently, the dosage was reduced to 20 mg/d, which was administered for another 1.5 months. After the first 3 months, the prednisone dose was tapered every month and the patient received the drug as 10-mg, 5-mg, and 2.5-mg tablets during the fourth, fifth, and sixth months, respectively. As a result, the prednisone was gradually reduced to a maintenance dose of 2.5 mg/d at the end of 6 months (). The patient discontinued the medicine 1 month after the maintenance dose was achieved. During the follow-up period, the patient underwent physical examination with repeated semen and biochemical analysis every 3 months (). The results of the semen analysis at the end of therapy showed a dramatically increased sperm count of 34.7×106/mL with normal follicle-stimulating hormone and testosterone levels.