A 68-year-old patient with a history of severe mental retardation and deaf-mutism secondary to meningitis in childhood. She consulted our emergency department due to pain and inflammation in the left hemiscrotal for more than 3 weeks, which did not subside despite antibiotic and anti-inflammatory treatment. Examination revealed a generalised increase in scrotal contents, more marked on the left side, with a painful testicle on palpation, firm consistency, smooth surface and thickened epididymis.
The right testicle was normal. Urine sediment revealed the presence of pyuria.
Ultrasonography revealed an enlarged, heterogeneous left testicle, with a medial area with multiple cystic cavities, some of which were hypoechogenic.
Diagnosed as advanced orchitis, the patient was discharged with analgesic-anti-inflammatory treatment.
Eight days later, the patient attended the urology department for a check-up, where palpation clearly delimited a nodule, which suggested a differential diagnosis of testicular neoplasia.
A radical left orchiectomy was performed, after determination of tumour markers (b-HCG, alpha-fetoprotein and LDH), which were normal.
Macroscopically, the section surface of the orchiectomy specimen showed thickening of the tunica albuginea, with haemorrhagic areas. The testicular parenchyma was increased in consistency, with the presence of whitish fibrous tracts and yellowish plaques on section. Microscopic examination revealed marked hypospermatogenesis with hyalinisation of the seminiferous tubules, as well as a chronic inflammatory process, consisting of histiocytes, abundant plasma cells and giant cells. Within some of these cells, characteristic Michaelis-Gutmann bodies with an owl's eye appearance were recognised, which were positive for Von Kossa staining, demonstrating their calcium composition and thus suggesting the diagnosis of MLP.
These inflammatory changes also partially affected the epididymis.
With the diagnosis of testicular and epididymal PML, treatment was completed with a course of fluoroquinolones for 3 months, after which the evolution is satisfactory and the patient is asymptomatic.