We present a 33-year-old public service employee who presented at the Surgical Outpatient Department with complaints of right scrotal swelling and pain of a week’s duration. Pain was dull, graded 4 on a scale of 10, insidious, non-radiating, aggravated by contact or touch and temporarily relieved by analgesics.
There was no associated urethral discharge, or lower urinary tract symptom. There was no prior history of trauma, strenuous physical activity or fever. He denied weight loss, chronic cough or loss of appetite. He was neither hypertensive nor diabetic. He had had surgery for intussusception at age 4 and hydrocoelectomy at 12. He was not aware of what type of intussusception or hydrocele he had. He was given antibiotics in another hospital before presentation.
He was afebrile. Genitourinary examination revealed a right hemi-scrotal swelling, normally situated right testis and an enlarged, firm, non-tender epididymis. There was a moderate-sized hydrocoele in the right side. The Urologist’s assessment was epididymitis.
Full blood count (FBC) was normal and Urine Culture showed no significant bacterial growth. Sperm count was 38 million per ml. Scrotal ultrasound scan (USS) showed an enlarged, right testis measuring 5.38 × 3.25 × 3.58 cm (32.83 ml) and a surrounding hydrocoele, and the ipsilateral epididymis appeared inflamed, enlarged and hypoechogenic with a thickened scrotal skin. The left testis measured 4.31 × 3.19 × 3.23 cm or 22.23 ml.
He subsequently presented to two other Urologists, who, on the suspicion of cancer, requested for alpha fetoprotein (AFP), beta human chorionic gonadotropin (HCG) and lactose dehydrogenase (LDH) all of which were within normal limits. A CT scan showed enlarged para-caval and pelvic lymph nodes with “secondary deposits” from a primary tumour in the right testis, as assessed by the radiologist.
On presentation in Kelina Hospital, the scrotal swelling had increased in size. He brought the Radiologist’s report of the abdominal CT scan suggesting a malignant testicular tumor. An agreement was reached between the medical team, the patient and his family for surgical intervention. Transinguinal scrotal exploration revealed an inflamed and heamorrhagic scrotal wall and 500 ml of straw-coloured fluid was evacuated from the tunica vaginalis.
The tunica vaginalis was opened and the epididymis was found to be tensely swollen. The vas deferens was hardened along its entire course. The testis was oedematous but the entire surface was smooth; no nodule was palpated on the testis.
It was decided that since the vas was palpably obstructed, a biopsy of the head of the epididymis would not cause any additional harm to the patient. An incision on the head of the epididymis yielded thick pus (Fig. 1). Pus was also found on the body of the epididymis.
At this point, a decision was taken to remove the testis completely. Orchidectomy was done with the vas ligated and transected around the deep ring. Procedure was well tolerated and patient was discharged home 2 days later. Specimens were sent for Pathologist’s assessment.
The patient was lost to follow-up until 7 weeks later when he presented with contralateral testicular pain graded 4 on a scale of 10. There was mild swelling and a fever one week prior to presentation which had resolved with self-medication.
Examination findings were an enlarged, left testis and epididymis, positive Phren’s sign and a firm, non-tender left lobe of the prostate on digital rectal examination. A prostatic massage was done and samples were sent for Gram staining and culture which yielded negative results. A sample of the initial abscess also did not grow any bacteria. FBC and urine culture were also normal. Scrotal USS only showed a moderate left vaginal hydrocoele. He was empirically started on parenteral antibiotics (Imipenem) and anti-Koch’s regimen on the suspicion of tuberculous epididymo-orchitis. He was discharged on anti-Koch’s medication and Azithromycin.
The pathologist’s report later came back to us with section of the testis showing granulomatous lesions composed of central necrosis surrounded by epithelioid cells, occasional multinucleated giant cells with characteristic horse shoe-shaped arrangements of the nuclei (Langhans’ giant cells). The lesion was surrounded by peripheral rims of lymphocyte and fibrous tissue. The lesions were more in the epididymis but extending also into the testis; however, AFB stain done was not able to demonstrate the acid-fast bacillus in the tissue, Grocott methenamine silver stain for fungi was negative (Fig. 2).
Patient stopped taking the antituberculous drugs and subsequently developed a discharging sinus on the side of the remaining testis. TB quantiferon gold test confirmed the diagnosis of tuberculosis, and he was re-commenced on the drugs for 5 months before this report. The sinus healed. He is still on his medications at the time of this report.
