A 47-year-old man presented to the emergency department complaining of left testicular swelling and pain for 3 weeks. Additional symptoms included intermittent lower abdominal pain and nausea without episodes of emesis. There was no dysuria, hematuria, urinary retention, urgency, frequency, or hesitancy with urination. Furthermore there was no weight loss, loss of appetite, night sweats, hemoptysis, night fevers, or cough. A chest radiograph was normal. Past medical history was relevant for a positive PPD in 2002, with no subsequent treatment.
On physical exam, the patient was afebrile, with normal heart rate, blood pressure of 159/127, and normal respiratory rate and oxygen saturation. His height was 5 feet 8 inches with a BMI of 20.83 kg/m^2. Head and neck exam was normal. There was no temporal artery tenderness. There was no meningismus. Palpation elicited reproducible pain at the left occipital insertion of the trapezius. The skin was warm and dry, with no rash, no laxity or noted thinning. His cardiac, pulmonary, and abdominal exams were unremarkable. His neurological exam revealed clear and fluent speech, intact cranial nerves II-XII, 5/5 strength throughout, and intact sensation. Gait was normal, and there was no nystagmus. He was alert and oriented. Laboratory investigations revealed complete blood count and chemistries within normal limits.
On physical examination the left testis seemed smoothly enlarged. There was associated boggy swelling of the left spermatic cord. The right testis was unremarkable. A firm right extratesticular mass, suspected to be epididymal, was present. Laboratory findings revealed: HCG 0; AFP less than 4.13; no pyuria. A urine AFB was performed based on the patient's history of a positive PPD. His urine was negative for AFB smear and culture.
Scrotal ultrasound was performed as part of the initial evaluation. Images demonstrated the presence of a 1.3 x 1.0 x 0.9 cm, well-defined predominantly, hypoechoic lesion in the upper pole of the right testicle (Fig. 1). This area was not tender to probe palpation. The lesion has slightly increased peripheral vascularity upon color Doppler interrogation. There was also noted edema with increased blood flow and small amount of fluid between the right epididymis and upper pole of the testicle. The remainder of the right testicle was normal measuring 4.4 x 2.1 x 2.5 cm. The left testicle and left epididymis were normal. Images of the upper left scrotal sac and distal inguinal canal demonstrated a serpiginous 3.0 x 1.8 cm structure with heterogeneous echogenicity which could not be separated from the left spermatic cord (Fig. 2). No abnormal vascularity was seen upon color Doppler interrogation. No peristalsis was present on real time imaging. Small bilateral hydroceles were noted.
The patient was referred for surgical management of a testicular mass. Preoperative diagnosis was right testicular tumor probable seminoma, and possible left patent processes vaginalis with omental herniation versus spermatic cord lesion. Postsurgical pathology revealed caseating granulomata in the upper pole of right testicle (Fig. 3) and also caseating granuloma in the left spermatic cord (Fig. 4). The right epididymis was normal. Cultures were positive for Mycobacterium tuberculosis.