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Immunosuppressed with renal transplant. One week enlarging right testis, no pain.
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The right testis is diffusely enlarged with heterogeneous and hypoechogenic echotexture (implying necrosis), with no evidence of vascular flow. The left testis shows prominence of the rete testis but is otherwise normal in size and echotexture, without vascular abnormalities. Right testis: ~ 27.6 mL, left testis: ~10 mL. The left epididymis is unremarkable, and the right one is of limited assessment.
Moderate right hydrocele 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 testis, likely chronic torsion.
MACROSCOPIC DESCRIPTION: Right testis: The tunica vaginalis is congested, hardened and thickened, with part of it received separate in the specimen pot 100 x 50 mm. 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 fibroinflammatory 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 tumor. The Gram stain highlights abundant colonies of gram-negative bacilli within testicular parenchyma. The PAS stain is negative for fungi.
DIAGNOSIS: Right testis, scrotal orchiectomy: Extensive testicular necrosis; mixed acute and chronic inflammation; colonies of gram-negative bacilli identified.