Testicular mass in a geriatric patient.

An 80-year old man was admitted suffering from a painful, enlarged right testicle for approximately one month. His medical history revealed a transurethral resection of the prostate for benign hyperplasia seven years before. The resection, performed in another hospital, was complicated by recurrent strictures of the urethra and several episodes of lower urinary tract infection. Internal urethrotomies and a holmium laser incision were used to resolve the strictures without lasting success. The patient did not have diabetes nor was he receiving any immunosuppressants. On presentation, genital examination revealed an indurated, tender, and enlarged right testicle. The patient was afebrile. White blood cell count was 7.9 x 10 9 /l (71% neutrophils), C-reactive protein was 3.6 mg/dl (normal limit <0.5 mg/dl), and alphafetoprotein was 11.6 ng/ml (normal limit <7.0 ng/ ml). Other routine laboratory tests, lymphocyte subsets, and nitroblue-tetrazolium test were within normal limits. HIV serology was negative. A scrotal ultrasound revealed a testicular mass of approximately 3 cm which was cystic in the centre and more solid in character at the periphery. The Doppler signal showed a halo of intense hyperaemic flow with absent flow centrally (figure 1A). Since a malignancy was suspected, a radical orchiectomy was performed. Pathological examination showed a soft cystic nodule in the testicle extending towards the epididymis and spermatic cord. Histological examination revealed a well-demarcated nodule characterised by a thick fibrous capsule, infiltrated by lymphocytes and plasma cells, and surrounding a collection of granulation tissue, and necrotic debris. A Grocotts's methenamine silver staining was performed which showed hyphae (figure 1B-D). figure 1. a. scrotal doppler ultrasound revealing a testicle containing a mass with a diameter of approximately 3 cm in the upper pole. the mass is hypoechoic and cystic in the centre and more solid in character at the periphery. the doppler signal shows a halo of intense hyperaemic flow with absent flow centrally. b-C. Grocott's methenamine silver stain showing hyphae. d. Histological examination revealing a well-demarcated nodule char-acterised by a thick fibrous capsule, infiltrated by lymphocytes and plasma cells, and surrounding a collection of granulation tissue, fungal hyphae, and necrotic debris. See page 139 for the answer to this photo quiz.