Immunosuppressed renal transplanted patient with one week increasing right testicle, no pain.
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The right testicle is diffusely enlarged with heterogeneous and hypoechogenic echotexture (implying necrosis), with no evidence of vascular flow. The left testicle shows prominence of the rete testes and is otherwise normal in size and echotexture, without vascular abnormalities. Right testis size: ~ 27.6 ml Left testis size: V. ~ 10 ml The left epididymis is unremarkable, and the right one is of limited assessment.
Moderate right testicle hydrocoele with a few septations. There is diffuse thickening of the scrotal wall on the right. Right iliac fossa transplanted kidney has normal sonographic appearances, no hydronephrosis.
Sonographic features are consistent with a right testicular infarction (likely subacute to chronic presentation). On surgery, this was confirmed as an avascular testicle, likely chronic torsion.
MACROSCOPIC DESCRIPTION: "Right testicle": The tunica vaginalis is congested hardened and thickened, with part of it received separate in the specimen pot 100x50mm. The tissue surrounding the testis is yellow white firm and mostly homogenous, with a few cross-cut vessels visible. On cut section the testicular parenchyma is soft brown and friable. No focal lesions are identified.
MICROSCOPIC DESCRIPTION: Sections of testis show extensive necrosis of seminiferous tubules and tunica albuginea with an outer adherent fibro-inflammatory exudate containing abundant neutrophils. Sections of epididymis show extensive fibrosis and a patchy lymphoplasmacytic chronic inflammation. No granulomas are identified. There is no evidence of vasculitis or tumour. The Gram stain highlights abundant colonies of gram-negative bacilli within testicular parenchyma. The PAS stain is negative for fungi.
D IAGNOSIS: Right testis, scrotal orchidectomy: Extensive testicular necrosis; mixed acute and chronic inflammation; colonies of gram-negative bacilli identified.