Giant necrotic lymph node metastases from testicular tumour with streptococcus pyogenes sepsis

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An 18‐year‐old man presented to the emergency department with a right inguinal swelling (Fig. 1) and signs of sepsis with a temperature of 40°C, tachycardia of 140 beats per minute and leukocytosis (white cell count = 12 × 109/L) and raised C‐reactive protein (210.6 mg/L). He had recently undergone orchidectomy followed by chemotherapy for a T2 N0 Mx mixed germ cell tumour of the right testes.
Despite initial concerns that this was a post‐operative inguinal abscess, clinical assessment suggested most likely that the differential was a giant lymph node metastases. Computed tomography was useful to confirm the diagnosis, delineate the relationship to neurovascular structures and guide appropriate intervention which was excision rather than incision and drainage (Fig. 2).
Mobilization and excision of the large bulky tumour mass was performed. On histopathology, this was reported as 95% embryonal carcinoma and 5% choriocarcinoma with 50% necrotic tissue (Fig. 3).
The culture taken from the specimen was a group A beta‐haemolytic streptococcus pyogenes, an organism well known to cause necrotizing fasciitis,1 which explained the fulminant septic presentation.
While differentials for inguinal swellings include hernias, pseudoaneurysms, psoas abscess, saphena varix, lymphadenopathy and cryptorchidism, it is important to consider inguinal lymph node metastases as a differential for inguinal swellings, including metastases from cancers of testicular, anal, lower limb skin, penile, cervical and perineal origins2 as well as lymphoma.3 For testicular tumours, 2% metastasize to the inguinal lymph nodes.

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