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Paper text:
sarcoidosis is a systemic inflammatory condition characterised by non  caseating epitheloid granulomata that classically affect the chest . extra 
pulmonary granulomata occur in over 75% of cases , but genitourinary sarcoidosis ( gus ) is very rare with only 60 cases reported in literature [ 2 , 3 ] . we present the case of a patient whom presented with weight loss , lymphadenopathy and testicular swelling , that ultimately was secondary to sarcoidosis .
in january 2009 , a 27year  old asian man initially presented to his general practitioner with a 4month history of weight loss totalling 9 kg and general malaise .
initial blood tests including full blood count ( hb 14.9g / dl , wbc 4.3 10/l , neutrophils 2.95 10/l , lymphocytes 0.72 10/l , esr 9 mm ) , urea and electrolytes , thyroid and liver function tests only revealed a mildly raised alkaline phosphatase .
interestingly , serum angiotensin converting enzyme level was elevated at 156 u / l ( normal range 852
an urgent ct ( computed tomography ) scan of the thorax , abdomen , pelvis and referral to the respiratory physicians were advised .
ct thorax findings raised the possibility of tuberculosis ( tb ) , lymphoma or sarcoidosis . to confirm a diagnosis , the patient underwent a bronchoscopy in february 2009 by the respiratory physicians and the bronchial brush biopsy .
a lymph node biopsy was carried out by the general surgical team and specimens were sent for tuberculosis culture and histology including haematological malignancies diagnostic services ( hmds ) .
the differential diagnosis of tuberculosis or lymphoma was considered . while awaiting cultures and pathology results on the above procedures the patient opted to have anti  tuberculosis treatment empirically .
unfortunately , the lymph node biopsy taken at presentation was not processed in error . in april 2009
a scrotal ultrasound scan showed a hyperechoic area within the left testis and he was referred to the urology unit .
additionally , despite negative culture findings , on balance , the patient was recommended to complete a six month course of anti  tb treatment . in may 2009
examination revealed a firm , non  tender mass , which included the left epididymis and testis .
of note , hcg ( human chorionic gonadotropin ) , afp ( alpha  fetoprotein ) and ldh ( lactate dehydrogenase ) were within normal range .
as malignancy could not still be ruled out , the patient underwent a left inguinal orchidectomy and inguinal lymph node biopsy . a frozen section not considered due to clinical and radiological findings .
typical non caseating granuloma with a giant cell in the centre ( hematoxylin  eosin , original magnification x 40 ) .
the patient was commenced on steroid treatment which was continued this for 2 years and is undergoing annual follow  up appointments with the respiratory physicians .
a testicular mass has many differential diagnoses including malignancy and , very rarely , sarcoidosis , as in the case described above .
urinary sarcoidosis ( gus ) can present with many testicular symptoms from acute pain to painless swelling ; with or without constitutional symptoms . clinical features suggesting a benign diagnosis of gus include bilateral lesions and afro  caribbean ethnicity ( three  fold higher incidence of gus ; just 3.5% of total testicular cancer cases ) [ 24 ] .
the initial investigations of a patient presenting with a testicular mass would include tumour markers ( afp , hcg and ldh ) .
sarcoidosis is not generally thought to cause false  positive results for afp or beta  hcg serum levels .
however , there are cases of testicular sarcoidosis with elevated tumour markers in literature ; sarcoidosis can cause a raised ldh , which is not a reliable diagnostic test for testicular malignancy . however , afp and beta  hcg serum levels should be part of the initial assessment of the patient presenting with a testicular mass . 
 
differential diagnosis of scrotal masses imaging is central to investigating testicular lesions but poorly differentiates between gus and malignancy .
the most common sonographic finding in gus is a hyperechoic mass affecting the testis or epididymis , however , as this is not specific to gus , a coarsened testicular echo  texture is also described [ 7 , 8 ] .
histological examination remains the most reliable way to confirm sarcoidosis and orchidectomy is the primary radical treatment for testicular mass suggestive of tumour .
when deciding to biopsy or remove the affected testis , conserving fertility and testicular function must be considered through sperm storage and avoiding an unnecessary orchidectomy . in one case  series ,
there are various approaches to testicular biopsy but they must consider potential malignant diagnoses , avoiding potential seeding of malignant cells . an inguinal approach open biopsy with intra 
operative clamping of the spermatic cord allows intra  operative frozen sections for histological examination ( and potential testicle preservation ) but can progress to radical orchidectomy if biopsy is equivocal or suggests malignancy .
other centres advocate radical orchidectomy whenever there is a potential diagnosis of testicular malignancy to prevent diagnostic delays or errors .
the fact that the lymph node biopsy taken at presentation was lost led to the unnecessary 6 months of empirical tb treatment and the orchidectomy .
one can argue that the diagnosis of testicular tumour was unlikely in the presence of enlarged superficial inguinal nodes and the initial clinical picture suggested , from the start , a systemic disease like lymphoma , sarcoidosis or tuberculosis with testicular involvement .
in addition , a repeat lymph node biopsy should have been considered , as nodes were superficial and palpable .
corticosteroids are indicated in gus as they can reduce testicular pain and may improve associated azoospermia [ 11 , 12 ] .
the incidence of sarcoidosis in patients with known testicular cancer is approximately 100fold higher than in a matched population of young caucasian men .
however , just 14% have a diagnosis of sarcoidosis before the development of testicular cancer .
all physicians who manage patients with sarcoidosis should be aware of gus and the association between sarcoidosis and testicular cancer .
in addition , an early discussion at the multi  disciplinary team ( surgeon , pathologist and radiologist ) should be considered .
furthermore , long  term drug therapy should be initiated after a precise histoplathological diagnosis .
we have discussed clinical parameters that indicate the benign diagnosis of gus but histological examination remains the most reliable way to exclude malignancy .
we present a case of a 27year  old man with a history of weight loss . 
 a chest x  ray demonstrated hilar lymphadenopathy and he was treated with anti tuberculosis treatment . 
 he noticed a painless left scrotal swelling and a scrotal ultrasound scan raised the possibility of testicular cancer . 
 he underwent an orchidectomy and histology confirmed a testicular sarcoidosis . 
 he was commenced on steroid treatment .