A painful swelling - medical case study

BACKGROUND: A 40-year-old man – Mr G – attends accident and emergency with a painfully swollen testis. He is seen by a specialist registrar – Dr A – who makes a diagnosis of epididymo-orchitis. Mr G is given a seven-day course of the antibiotic co-amoxiclav and advised to see his GP for follow-up.

A week later Mr G attends for an appointment at his local general practice surgery. He is seen by Dr B who notes the A&E attendance and antibiotic prescription. The patient reports improvement in his condition but there is still some slight swelling. Dr B prescribes a further seven-day course of antibiotics but this time with ofloxacin.

Eight days later Mr G phones the practice requesting an urgent appointment. He is concerned that the swelling has not cleared with the second course of antibiotics. Dr B examines the patient again and identifies a small non-tender cyst in the left epididymis but the testis is "normal". Dr B reassures the patient and instructs him to return in two weeks if the symptoms have not settled.

Two weeks later Mr G attends the practice again complaining of a persistent and painful swelling. He sees Dr B and expresses his worry that he might have testicular cancer. Dr B notes "Left testicular pain persists, lump adherent to upper pole" and he refers the patient for an ultrasound investigation of the testicle and issues a further prescription of the antibiotic ciprofloxacin.

Just over two weeks later an ultrasound investigation is conducted and Mr G is referred to an urologist the next day. The urologist finds several focal lesions consistent with tumour on the scan. On examination he detects a hard tender mass at the upper pole of the left testis. He notes that the pain and position are not entirely typical of testicular tumour but decides it is necessary to explore the testis and probably carry out an orchidectomy. Two days later the procedure is undertaken and histological analysis confirms a diagnosis of seminoma. A CT scan shows enlargement of the peri-aortic lymph nodes on the left side so Mr G undergoes both chemotherapy and radiotherapy. He later reports prostatitis and neuropathic pain as a result but his prognosis is good.

Four months later a letter of claim is received at the practice from solicitors acting on behalf of Mr G. It alleges that Dr B was negligent in not making an urgent referral before involvement of the lymph nodes necessitated the need for chemotherapy and radiotherapy.

ANALYSIS/OUTCOME: Dr B contacts MDDUS and expert reports are commissioned. A urologist comments on the case stating that the tumour could have been present in the testicle up to six months before the patient attended Dr B but it is not possible to determine if it caused the epididymo-orchitis. He writes: “Epididymo-orchitis is a relatively common condition, which causes swelling of the testicle. It would therefore camouflage any intra-testicular lumps and made diagnosis of the tumour much more difficult.”

The expert concludes that Dr B at the initial presentation would have had no reason to suspect anything more serious than epididymo-orchitis and later made the referral to ultrasound at a "prudent stage" when the symptoms had not been resolved by antibiotics. The fact it was not an urgent referral would have led to a delay of no more than about a week and this would have made no difference to the staging of the tumour, the enlargement of the peri-aortic lymph nodes and thus the treatment options and long-term prognosis.

Based on the expert reports MDDUS was able to make a firm rebuttal of the claim and it was subsequently abandoned.

KEY POINTS

• Beware of infections or other conditions possibly causing or masking other more serious conditions.
• Consider carefully the need for an urgent referral in persistent unresolved infections.
• Keep clear notes justifying clinical decisions.