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 49-year-old heterosexual man who was diagnosed with HIV infection 3 years earlier following screening when hospitalised for pneumococcal pneumonia was managed with once daily darunavir 800 mg, ritonavir 100 mg and emtricitabine 200 mg/tenofovir disoproxil 245 mg. His current CD4 level was 370 cells/mm3 and viral load was <40 copies/ml. He trained regularly at the gym and was a keen amateur boxer. He wished to conceive with his wife but complained of lack of energy and reduced libido. Serum total testosterone levels were 5.5 pmol/l, calculated free testosterone 150 pmol/l, SHBG 14 nmol/l, FSH 4 IU/ml, LH 5 IU/ml and prolactin 89 mIU/ml. He admitted to regular use of oxandrolone and stanozolol over several years.