Inflammation and infection Patient with antiphospholipid syndrome presenting with testicular torsion-like symptoms Arnav Srivastava a, * , Joan Ko a , Joy Ogunsile b , Alison Moliterno b , William H. Westra c , Alice Semerjian a a James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA b Division of Hematology, Johns Hopkins Medical Institutions, Baltimore, MD, USA c Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA article info Article history: Received 13 August 2017 Accepted 30 August 2017 Available online 6 September 2017 Keywords: Testicular torsion Coagulopathy Antiphospholipid syndrome abstract Testicular torsion, a urological emergency, occurs due to absence of testicular blood supply secondary to a mechanical twist of the spermatic cord. The authors describe a 28-year-old male who presented with torsion symptoms, first in the left testicle and four months later in the right testicle. Doppler ultrasound and surgical exploration revealed disruption of blood flow but no evidence of spermatic cord twisting. Additionally, physical examination findings at the time of presentation were inconsistent with testicular torsion. Hematologic workup revealed triple positive antiphospholipid syndrome as the cause of testicular ischemia. The patient was successfully treated with aspirin and therapeutic heparin. © 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction Testicular torsion, a urological emergency, occurs due to twisting of the spermatic cord. Consequently, testicular blood supply is compromised, resulting in testicular infarction. The au- thors present a patient who experienced metachronous bilateral episodes of testicular pain and diminished arterial flow, suspicious for torsion. The patient exhibited classic testicular torsion symp- toms, but scrotal exploration revealed no spermatic cord twisting after both events. After hematologic workup, the patient's pre- sentation was attributed to microthrombi in testicular circulation secondary to antiphospholipid syndrome (APLS). Testicular infarc- tion due to hypercoagulable states are rarely described in the literature; only two previous reports attributed the infarction to APLS. 1e5 This is the first reported case of APLS presenting with testicular infarction as its only manifestation. 2. Case presentation A 28-year-old man with no past medical history presented to an outside hospital with a 3-day history of acute abdominal pain, left testicular pain, and vomiting. The patient's episode began after a weight-lifting session. An ultrasound showed no flow to the left testicle with concern for testicular torsion. The patient underwent surgical exploration and bilateral orchidopexy at that institution where no evidence of torsion was found. Two days later, the patient presented at the authors' institution with worsening left testicular pain despite orchidopexy. Notably, the patient denied any difficulty voiding, changes in urine color, fever, flank pain, penile discharge, recent sexual activity, or testic- ular trauma. Physical exam revealed a tender left testicle, but no swelling or erythema of the scrotum. The patient had a preserved cremasteric reflex. Laboratory values showed a white blood cell count of 12.9 Â 10 3 /cubic mL and platelet count of 259 Â 10 3 /cubic mL. Scrotal duplex ultrasound revealed normal blood flow and ho- mogenous echotexture in the right testicle. The left testicle had no arterial flow, some preserved venous flow, and minimal heteroge- neous echotexture. Scrotal exploration revealed no twisting of the left spermatic cord, but the left testicle appeared non-viable with a blue mottled appearance. After left orchiectomy, the patient's pain subsided, and he was discharged. Four months later, the patient returned with a one-day history of acute right testicular pain. Similar to his previous presentation, his review of systems was otherwise negative and his physical exam was normal except for testicular tenderness. * Corresponding author. 600 N. Wolfe Street, Park Building, Room 223, Baltimore, MD, 21287, USA. E-mail addresses: asrivas9@jhmi.edu (A. Srivastava), jko16@jhmi.edu (J. Ko), fogunsi@jhmi.edu (J. Ogunsile), amoliter@jhmi.edu (A. Moliterno), wwestra@jhmi. edu (W.H. Westra), asemerj1@jhmi.edu (A. Semerjian). Contents lists available at ScienceDirect Urology Case Reports journal homepage: www.elsevier.com/locate/eucr http://dx.doi.org/10.1016/j.eucr.2017.08.010 2214-4420/© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Urology Case Reports 15 (2017) 26e27