Seminoma in undescended testes presenting with acute renal failure

Sir,

A 17-year-old boy was admitted with a high grade fever for 2 days along with alteration in sensorium and decrease in urine volume. The fever was high grade, associated with chill and rigor. He had a huge swelling in the lower part of the abdomen, which according to his parents had been progressing over last 6 months. On examination, the patient was unconscious, febrile with a pulse rate of 110/min. Respiratory rate 26/min with acidotic pattern. There was no pallor or lymphadenopathy. Chest examination revealed bilateral coarse crepitations. Abdomen examination revealed single testes in the scrotum on the left side, a huge mass in the lower part of abdomen, firm in consistency, not fixed to overlying skin, with a side-to-side mobility. There was no pulsation or audible bruit. Cardiovascular system was normal. Routine blood report revealed hemoglobin 11.8 mg/dl, total leucocyte count 17,000/cu mm with polymorphonuclear leukocytosis, urea 234 mg/dl, creatinine 8 mg/dl. Urine showed plenty of pus cells. Patient was treated conservatively with intravenous (IV) antibiotics and IV fluids. The patient was put on dialysis and regained consciousness after 2 days. Ultrasonography showed a huge retroperitoneal mass with bilateral hydroureteronephosis. No lymphadenopathy could be documented. Right scrotal sac was empty with a normal left testis. A non-contrast computed tomography scan revealed ovoid well-defined, soft-tissue attenuation mass, measuring about 101 mm × 127 mm in the midline of the lower abdomen, with absent right spermatic cord [Figure 1]. The impression was, testicular carcinoma arising from the right intraabdominal undescended testis. At the end of 1^st week, there was an improvement of clinical condition with normalization of total leucocyte count and his serum urea and creatinine values came down to 43 mg/dl and 1.6 mg/dl respectively. After stabilization of patient's condition, the patient underwent orchiedectomy followed by radiotherapy. Histopathologically, the mass was confirmed as seminoma.

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Figure 1

Non contrast computed tomography scan of abdomen showing large pelvic mass (marked)

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Seminoma affects young men typically between the ages of 30 and 55 years and accounts for approximately 50% of testicular germ cell tumors. The cure rates is very high due to its extreme sensitivity to chemotherapy and radiotherapy.[1] The prognosis of pure seminoma is excellent.[2] Majority of undescended testes are located distal to the external inguinal ring and they are palpable. Non-palpable undescended testes are generally located in the inguinal canal, but a very few of them are located intra-abdominally.[3] About 66% of undescended testes are located distally to the external inguinal ring, 16% in the inguinal canal, 10% are intraabdominal and 3% are surgically absent.[4] As seminoma of testes is common between 30 and 55 years of age with pure seminoma being rare, here we are presenting a case of pure seminoma testes admitted with urinary tract obstruction leading to urinary stasis and urosepsis leading to acute renal failure.