A 15-year-old patient with no previous history of interest.
He was seen in the emergency room due to vomiting and epigastric pain for three days, and reported loss of 7 kg of weight in the previous two months.
Physical examination revealed moderate mucocutaneous stiffness, hepatomegaly of the fingertips, and epigastric pain to severe constipation.
Painful exploration revealed a hard consistency, irregular surface and non-irregular left test (3 or 4 times more than normal).
The patient was reinterrupted and confirmed to us that approximately a year ago he had noticed a painless and progressive increase in the test.
Only 35% hematocrit, 11.3 gr/dl hemoglobin and 2802 U/L LDH stood out in the emergency analysis.
Abdominal and testicular ultrasound demonstrated the existence of a very increased left test of heterogeneous echogenicity size, with foci of necrosis and liquid areas; and in the liver large images suggestive of metastasis.
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The chest X-ray showed the existence of lung metastases and a discrete pleural effusion, which resulted in multiple aspirations of pleural fluid.
Twelve hours after admission, a CAT scan showed extensive metastases, with multiple bilateral pulmonary nodules, right pleural effusion, mediastinal lymphadenopathy, retroperitoneal metastases, hepatomegaly with metastatic involvement.
There was no free intraperitoneal fluid.
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Blood samples were obtained for testicular markers: alpha-fetoprotein 15000 ng/ml and betaHCG 200,000 mIU/ml. Orchiectomy was scheduled for the next day.
Thirty-six hours after admission, hypovolemic shock with rapid onset of pain and abdominal bulging occurred, requiring urgent laparotomy after abdominal ultrasound, which showed a large amount of intraperitoneal fluid.
During laparotomy, extensive metastatic involvement was found in the tail of pancreas, spleen and liver with rupture of splenic and liver metastases and massive hemoperitoneum due to diffuse liver hematoma.
Elective liver resection was performed with suture and closure of bleeding areas with a left radical orchiectomy.
Macroscopic anatomopathological examination describes the following: "shortness of radical orchiectomy, weighing 233 gr and measuring 8x9x5 cm, accompanied by 7 cm of cord; almost serial sections show total necrosis and testicular parenchymal
Microscopic histopathology of the testicle showed a mixed germline malignant neoplasm in which areas like embryonal carcinoma, endodermal sinus tumor, choriocarcinoma and teratoma are observed.
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The spleen measured 15x7x3 cm and weighed 180 gr. serial sections six rounded nodular, whitish forms with central necrosis.
Sepsis confirms that splenic lesions are metastases of testicular neoplasia.
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Forty-eight hours after surgery the patient suffered a new picture of hypovolemic shock with evident signs of intra-abdominal bleeding, so a new laparotomy was performed, verifying the existence of a lobe of inexercise left burst.
