Deposits observed on the inside of a hydrocele sac yielded an unexpected association.
CASE HISTORY
A man of 53 was referred to the urology clinic with a slowly enlarging right testicle. Clinically, he had a hydrocele which was so thick-walled as to limit proper palpation of the testicle. However, an ultrasound scan confirmed the diagnosis and indicated that the testicle was normal. In addition, the patient was noted to have severe deformities in the small joints of his hands with ulnar deviation and volar subluxation. Although arthritis had never been formally diagnosed, he had undergone an ulnar nerve decompression several years earlier. Later on, a rheumatologist agreed that he exhibited all the features of rheumatoid arthritis.
During the Lord's repair of his hydrocele, brownish deposits were seen studding the inside of the tunica vaginalis (Figure 1) and biopsies were taken. His postoperative recovery was slowed by a low-grade pyrexia, without evident sepsis. The biopsies were reported as vascular fibrous tissue with foci of necrobiosis surrounded by palisaded macrophages—i.e. a rheumatoid type tissue response.
Figure 1.
Histological appearance of brown deposits on tunica vaginalis
COMMENT
The main target of the autoimmune response in rheumatoid arthritis is synovium, but extra-articular manifestations of the disease are common, particularly subcutaneous rheumatoid nodules. There are numerous case reports citing evidence of rheumatoid nodular and non-nodular inflammation involving more unusual locations such as the nasal septum,1 larynx,2 trachea,3 pulmonary tree,4 pericardium,5 and mitral and aortic valves.6,7 Even intraspinal nodules have been identified8 and sometimes the symptoms from the sites of inflammation precede the articular symptoms. There are anecdotal reports of subcutaneous nodules regressing with colchicine and D-penicillamine therapy and enlarging with methotrexate. However, there are no published reports of the tunica vaginalis being affected.
Acknowledgments
I thank Professor Terry Cook, Department of Histopathology, for providing the histological images and report.
References
- 1.Belloso A, Morar P, Estrach C, Helliwell T, Jackson S. Rheumatoid nodule of the nasal septum. J Laryngol Otol 2001; 115: 853-5 [DOI] [PubMed] [Google Scholar]
- 2.Sørensen WT, Møller-Andersen K, Behrendt N. Rheumatoid nodules of the larynx. J Laryngol Otol 1998; 112: 573-4 [DOI] [PubMed] [Google Scholar]
- 3.Ip MSM, Wong MP, Wong KL. Rheumatoid nodules in the trachea. Chest 1993; 103: 301-3 [DOI] [PubMed] [Google Scholar]
- 4.Filho JSR, Soares MF, Wal R, Christmann RB, Lin CB, Schmitt FC. Fine-needle aspiration cytology of pulmonary rheumatoid nodule. Diagn Cytopathol 2002;26: 150-3 [DOI] [PubMed] [Google Scholar]
- 5.Butman S, Espinoza LR, Del Carpio J, Osterland CK. Rheumatoid pericarditis: rapid deterioration with evidence of local vasculitis. JAMA 1997;238: 2394-6 [DOI] [PubMed] [Google Scholar]
- 6.Chand EM, Freant LJ, Rubin JW. Aortic valve rheumatoid nodules producing clinical aortic regurgitation and a review of the literature. Cardiovasc Pathol 1999;8: 333-8 [DOI] [PubMed] [Google Scholar]
- 7.Shimaya K, Kurihashi A, Masago R, Kasanuki H. Rheumatoid arthritis and simultaneous aortic, mitral, and tricuspid valve incompetence. Int J Cardiol 1999;71: 181-3 [DOI] [PubMed] [Google Scholar]
- 8.Sasaki S, Nakamura K, Oda H, Fukasawa K, Kurokawa T. Thoracic myelopathy due to intraspinal rheumatoid nodules. Scand J Rheumatol 1997;26: 227-8 [DOI] [PubMed] [Google Scholar]