Our patient was a 63-year-old retired gentleman, weighing 64 kilograms and 1.8 meters tall. He had no significant family history and drank only occasionally. At presentation he was trying to give up a 40 pack-year smoking habit. His medications were predominately analgesics but also a bisphosphonate and prednisolone 20 mg.\nHe had a history of SLE, haemolytic anaemia, recurrent idiopathic thrombocytopenia purpura and recent chemotherapy (6 months previously) for diffuse large B-cell lymphoma.\nHe presented to clinic with a tender, diffusely enlarged right testicle, and was also noted to be suffering from night sweats, a 7 kg weight loss, and splenomegaly (previously noted prior to treatment for lymphoma).\nTumour markers were normal, but an ultrasound scan of his right testicle showed a non-homogenous abnormality inferiorly (), in keeping with a recurrence of lymphoma or a primary malignancy [].\nGiven his history and symptoms, he was urgently referred to the urologists who decided to proceed with a right orchidectomy.\nHistology of the right testis showed a granulomatous orchiditis. A Ziehl-Neelson (ZN) stain showed a large number of acid fast bacilli (AFB) which, given the morphology and absence of caseation, was most consistent with a NTM infection. Unfortunately, no sample had been sent for culture, but given the histological findings and clinical presentation, this was considered most likely to be Mycobacterium avium-intracellulare (MAI) infection.\nHe recovered well post operatively, and, as a CT scan showed a right apical lung lesion, he was referred to the local respiratory physician for further investigation and management.\nBronchial washings of the right upper zone and left lingula were positive for AFB. He was commenced on conventional quadruple anti-tuberculous therapy pending formal identification of the AFB. The organism was subsequently confirmed as MAI, and therapy was switched according to the British Thoracic Society guidelines [].
A 57-year-old HIV-infected man who attended for routine HIV clinical review described increased fatigue, reduced libido and erectile dysfunction unresponsive to phosphodiesterase-5 inhibitor use. He had stable type 2 diabetes mellitus (controlled by metformin 1 g b.d). He presented 2 years earlier with pulmonary tuberculosis and HIV-1 infection with nadir CD4 count 50 cells/mm3 and viral load >100,000 copies/ml. His HIV infection was well controlled (CD4 540 cells/mm3, viral load <40 copies/ml) by Maraviroc 300 mg b.d. and Kivexa (abacavir 600mg/lamivudine 300 mg o.d.). Physical and genital examination was normal. Investigations included early morning total testosterone 6.2 nmol/l (normal range 9.4–37 nmol/l), calculated free testosterone 142 pmol/l (normal range 174–729 pmol/l), LH 16 IU/ml (normal range 1–9 IU/ml), FSH 24 IU/ml (normal range 1–10 IU/ml) and SHBG 22 nmol/l (normal range 15–40 nmol/l). A diagnosis of primary hypogonadism was made. Topical testosterone treatment (Testogel, one sachet per day) was initiated with resolution of symptoms.