Testicular tumour: Unusual presentation of an unusual infectious disease

Abstract

Background: Testicular tumour of Coccidioidomycosis is an extremely rare example of infectious disease. It usually affects the respiratory system especially in immunocompromised patients. Extrapulmonary Coccidioidomycosis accounts for 0.5% of cases with testicular involovement in 1.5% among them. Case Description: A 54 y gentleman presented with an increasing painless swelling in the left scrotum for 5 m with a history of diabetes mellitus for 9 y. Examination findings revealed an approximately 4.5 × 3 cm hard lump in the upper pole of the left testis with small hydrocele and varicocele. Laboratory values of serum AFP, β-hCG and LDH were within normal limits with high blood glucose level (351 mg/dl) and HBA1c (8.1). USG of the scrotum showed bilateral minimal hydrocele with left varicocele. CECT abdomen and pelvis showed bilateral hydrocele with normal testes, left varicocele and bilateral inguinal lymphadenopathy. Surgery was planned for excision of the lump with or without orchidectomy with inguinal lymph node biopsy via high inguinal approach. At surgery, an approximately 4 × 2 cm left spermatic cord hard tumour mass encircling the vessels and the vas deferens just proximal to the testis associated with thrombosis of the testicular vein, secondary varicocele, minimal hydrocele and multiple left inguinal lymph nodes was found. Excisional biopsy of the left spermatic cord mass and inguinal lymph nodes was done preserving the spermatic cord structures and the testis. Histopathological report showed reactive lymphadenitis from the inguinal lymph nodes and coccidioidomycosis with granulomatous lesion from the left spermatic cord mass. Treatment was started with a daily dose of 300 mg of Fluconazole for 6 m. After 2 w of initial therapy, serous collection which developed was drained and it took 3 m for the wound to heal. Discussion: Coccidioidomycosis is an infectious fungi which very rarely manifest as a surgical disease. Definitive diagnosis is with histopathological examination. Besides, other serological tests such as IgM, IgG antibodies, complement fixation test etc are supportive. Treatment consists of Fluconazole or Amphotericin B though duration is not standardized. Conclusion: Although uncommon, Coccidioidomycosis needs to be ruled out in testicular tumour especially in immunocompromised patients preventing unnecessary orchidectomy.