A 21-year-old male patient with a history of allergic rinitis, lipid myopathy, hypertriglyceridemia, sinus tachycardia, cardiac preexcitation syndrome, labile arterial hypertension and ipsilateral anal fistula who had undergone surgery.
Vomiting with blood threads were added to this episode; moderate hematuria was the most frequent laboratory requested in the emergency department.
Abdominal ultrasound showed images compatible with multiple retroperitoneal adenopathies; testicular examination revealed a lesion compatible with neoplasia of the lower pole of the left testicle.
The HCG was strikingly high.
The patient is admitted presenting two days after episodes of dyspnea as well as small hemoptoic sputum, febrile syndrome and affectation of the general state.
The anteroposterior chest X-ray showed images compatible with basal pneumonia and metastasis.
The symptoms previously exposed continued to increase, causing cardiorespiratory arrest with massive pulmonary hemorrhage (large amount of blood aspirated by the endotracheal tube) and the patient died nine days after admission.
1.
Autopsy
External aspect: only the enlargement of the left testicle stood out.
Internal aspect:
Cervical involvement: numerous supraclavicular lymphadenopathies were observed in the right, soft, red and with a diameter between 0.8 and 1.5 cm. In the airway and digestive tract remnants were appreciated
Chest wall thickness: The lungs weighed 3100 g together presenting multiple hemorrhagic nodules with a tumoral appearance with diameters ranging from 0.5 to 3.5 cm. Among the nodules, the pulmonary parenchyma was consolidated as hemorrhagic.
There was a lymph node of metastatic aspect and hemorrhagic surface of 4.5 cm in diameter, near the carina and another right paratracheal with similar characteristics.
Other smaller sizes were also observed in both pulmonary hilium, paraesophageal region and paraaortic region.
The heart weighed 280 gr and showed no significant changes as well as vascular structures at this level.
Fetal stricture: The liver weighed 2250 gr and had a firm consistency and a 'mottled nut' cut surface.
In the right lobe there was a hemorrhagic metastasis of 4 cm of maximum dimension and another in the left of 1.5 cm. The biliary tract was permeable and at the level of the gallbladder there was biliary mud.
No significant changes were observed in the spleen, stomach, pancreas, intestines, kidneys and adrenal glands.
In retroperitoneal situation and in contact with the internal edge of the right kidney there was a large necrotic tumor mass that seemed to compromise the vessels of the renal hilium; next to it several lymph nodes with neoplasic appearance were isolated.
The abdominal aorta showed mild atherosclerosis; in the inferior vena cava a tumor thrombus was observed.
In the left testicle, 30 gr, larger than the contralateral, there was an indurated and hemorrhagic tumor of 3 cm in diameter.
The right testicle showed no abnormalities.
- Head: No macroscopic changes were observed at this level.
Microscopic description:
The neoplasm consisted of a pleomorphic cell population composed of large cells with large cytoplasm and vesicular nuclei, with prominent zygotic follicleoblasts, together with a second population of bi- or multinucleated cells.
Subtotal hemorrhagic necrosis was evident and only small nests of tumor cells were observed peripherally and around the vessels (invasive vascular walls and lumens were observed in almost all locations).
In the lungs, the neoplasm was accompanied by massive interstitial and intraalveolar hemorrhage.
In the non-completely compromised lymph nodes (right supraclavicular lymph nodes), there were small tumor nodes along with marked sinus histiocytosis with hemophagocytosis and plasmacytosis.
The pararenal tumor mass corresponded to the corresponding renal hilium and hilian vessels.
Hepatic metastases were equally hemorrhagic and only in its periphery it was possible to appreciate preserved cells; at this level a very discreet perivenular steatosis and minimal portal and periportal inflammation were also observed.
