Involvement of urinary and genital structures in Henoch-Schönlein purpura (HSP) is fairly common in children, but unusual in adults. We present the case for including the spermatic pedicle among the structures that can be involved.
A 59-year-old man was referred for abdominal and right testicular pain lasting for 3 weeks, and arthralgia and purpura for 1 week. His temperature was 38.1°C. Sensitive right lower abdominal quadrant, increased by palpation, palpable purpura on lower limbs (Figure 1), and knee and wrist arthralgia were present, but urological examination was normal. Laboratory tests showed hyperleukocytosis, elevated C-reactive protein, and normal serum creatinine, urinalysis and liver function tests. Investigations for anti-nuclear and antineutrophil cytoplasmic antibodies, rheumatoid factor, and cryoglobulinemia were negative, as well as tests for human immunodeficiency virus, hepatitis B and C virus, and blood cultures. Cutaneous biopsy of palpable purpura disclosed a small leukocytoclastic vasculitis with deposits of immunoglobulin A (IgA) in the blood vessel wall. Computed tomography (CT) scan demonstrated right spermatic pedicle thickening (Figure 2). Imaging using [18F]-2-fluoro-deoxy-D-glucose showed accumulation of the tracer limited to the right spermatic pedicle. Diagnosis of HSP was established, indicated by spermatic pedicle involvement. Treatment with prednisone 1 mg/kg/day progressively tapered over 6 months resulted in dramatic improvement of clinical signs and laboratory and CT scan abnormalities.
HSP is a small-vessel vasculitis characterized by IgA and C3 deposits in the vessel wall that cause palpable purpura, arthralgia or arthritis, abdominal pain, gastrointestinal bleeding, and renal disease, predominantly in children1.
Involvement of urinary and genital structures is observed in 2% to 38% of patients in pediatric series1, but it is unusual in adults. Involvement of the scrotal wall, glans penis, epididymis, testis, spermatic cord, ureter, and bladder has been reported2,3,4. The spermatic pedicle should be added to this list.