A Rarely Complete Cold-in-Hot Sign in a Subclinical Testis Torsion
Divisions of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
A 15-year-old man presented to our emergency department with 2 days of intermittent left scrotal pain. He denied nausea, vomiting; nor any past history. Physical examination revealed bilaterally positive cremasteric reflexs without a high-riding testis. However, the left testis was hard and swollen. Color-Coded Doppler Sonography showed equivocally decreased left testicular blood flow. Leukocytosis and elevated C-reactive protein were noted. To differentiate from epididymo-orchitis, a scrotal scintigraphy was arranged immediately, which revealed a rarely large “cold” lesion in “hot” lesions in the left testis. Surgical exploration confirmed torsion and a diffusely ischemic left testis. Orchiectomy was subsequently performed. Pathology revealed an ischemic testis, compatible with scintigraphy findings. Importantly, the impression of testis torsion shouldn’t be ruled out in all adolescent male. Testicular torsion can present with a “cold-in-hot” sign on scintigraphy, representing diffuse ischemia after a delay of at least 24 hours due to subclinical torsion.