Tryptophan synthase Basic principles Simplified

The left testis, epididymis and cord structures were normal. His serum ��-feto protein , ��-human chorionic gonadotropin and lactic dehydrogenase were normal. He had an ultrasound scan of the Tryptophan synthase testis which revealed a 20?mm well-circumscribed ring-shaped intratesticular lesion in the lower pole of the testis with alternate hypoechoic and echogenic layers (onion skin appearance) and normal surrounding testis tissue (figure 1).1�C3 There was no evidence of Doppler flow within the lesion and the lower pole of the right testis (figure 2). There was no hydrocoele or other abnormalities. The case was discussed at our multidisciplinary team meeting and the impression was that this could be an epidermoid cyst but a testicular malignancy was also likely. As such he was offered a right radical orchidectomy or referral to another centre offering frozen section for exploration. He opted for a right radical orchidectomy with insertion of a testicular prosthesis. The histology of the specimen was eventually reported as an epidermoid cyst of the testis. Figure?1 Hypoechoic ring-shaped lesion with no evidence of Doppler flow. Figure?2 A well-circumscribed ring-shaped intratesticular lesion in the lower pole of the testis with alternate hypoechoic and echogenic layers (onion skin appearance) and normal surrounding testis tissue in keeping with an epidermoid cyst. Learning points It is possible to make a diagnosis of an epidermoid cyst from ultrasound imaging. If the diagnosis is in doubt then the use of frozen section at time of surgery should be considered. Footnotes Contributors: OEM and ND were involved in the conception and writing of the article and also approved the final draft. Competing interests: None. Patient consent: Obtained. Provenance and peer review: Not commissioned; externally peer reviewed.""On admission, that is, at zero hour, the young patient was dehydrated, with sunken eyes and in agony. Blood pressure (BP) was 106/80?mm?Hg and pulse rate 100/min. The core temperature was 38.4�� C but the peripheries were cold on touch. She looked pale and toxic. Uterus was full term with strong uterine contractions and head was engaged, fetal heart sound was absent. Vaginal examination revealed fully dilated cervix, 1?cm caput and head at plus one station. Examination of other systems revealed no abnormal signs. Her haemoglobin (Hb%) was 5?g/dL, total leucocyte count 20?000/mm3 and platelet 1?43?000/mm3. We decided to deliver the patient by low forceps under intravenous sedation. It was an easy outlet forceps delivery. A stillborn baby was delivered. There was no moulding of the head of stillborn baby. After placental delivery of the patient started bleeding per vagina and the uterus was found to be flabby and atonic. She was given intravenous crystalloids with 40 units oxytocin infusion, and manual uterine massage. However, she still continued to bleed; intravenous carboprost 250??g and per rectal misoprostol 800??g was also given.