Cholesterol granuloma of the right epididymis mimicking an acute scrotum

Abstract

Dear Sir,I am B. Spajic, the urologist from Clinical Departmentof Urology, Sestre Milosrdnice University Hospital,Zagreb, Croatia. Recently, we had a rare case of acholesterol granuloma of the right epididymis at ourdepartment, showing clinical signs of acute scrotum. Thecase described here appears to be the second reportingcholesterol granuloma in the epididymis and the first onepresenting with clinical signs of acute scrotum.A 31-year-old patient was admitted to our clinic forthe evaluation of acute pain in the right hemiscrotum. Atpresentation, acute scrotum was diagnosed and torsionof right testicular or epididymal appendices was suspected.During examination a severely painful nodular mass waspalpable. The patient had no voiding symptoms or fever,and there were no signs of acute infection (normal whiteblood cell count and urinalysis). The patient’s medicalhistory was uneventful regarding tuberculosis,sarcoidosis, syphilis or fungal infections. The patientdenied recent trauma or sexual intercourse. Chest roent-genogram showed no inflammatory or infiltrative process.Echosonographic finding disclosed an enlarged,hyperechoic and heterogeneous lesion of the epididymis,predominantly in the body and the head, measuring ap-proximately 10 × 20 mm, and moderate hydrocele(Figure 1A). The patient underwent urgent explorationof the right hemiscrotum. During surgery no testiculartorsion or signs of acute epididymitis were observed,but hydrocele was found. A tumor-like induration wasfound in the enlarged head and body of the epididymisand total epididymectomy was easily performed.Pathohistologically, the lesion was located in the head ofthe epididymis and consisted of a zone of necrosis thatinvolved ducts and interstitial connective tissue and wasnot associated with an acute inflammatory response.Inflammatory infiltrates were scanty and consisted oflymphocytes and macrophages. In clusters of mono-nuclear inflammatory cells, cholesterol crystals and giantcells of foreign body type were found (Figure 1B). Thespecimen was diagnosed as cholesterol granuloma of theepididymis. The values of total serum cholesterol werenormal (142 mg/dL).Cholesterol granuloma is an entity consisting offibrogranulomatous tissue containing numerous crystalsof cholesterol and foreign body giant cells [1]. Its patho-genesis is yet to be discovered. Cholesterol granulomais occasionally found in the middle ear [1]. Nodules andmasses are frequently encountered in the epididymis.Their differential diagnosis includes chronic granuloma-tous epididymitis, adenomatoid tumour and benignparatesticular neoplasms. Granulomatous lesions of the