An unusual cause of gynaecomastia in a male

Summary: Beta-human chorionic gonadotropin (ßhCG) is normally produced by syncytiotrophoblasts of the placenta during pregnancy and aids embryo implantation. However, it is also secreted in varying amounts in non-pregnant conditions commonly heralding a neoplastic process. We present a case of 50-year-old man, who presented with bilateral gynaecomastia with elevated testosterone, oestradiol, suppressed gonadotropins with progressively increasing levels of human chorionic gonadotropin (hCG). Biochemical and radiological investigations including ultrasonography of testes, breast tissue, MRI pituitary and CT scan full body did not identify the source of hCG. FDG PET scan revealed a large mediastinal mass with lung metastasis. Immunostaining and histological analysis confirmed the diagnosis of primary choriocarcinoma of the mediastinum. It is highly aggressive and malignant tumor with poor prognosis. Early diagnosis and management are essential for the best outcome. Learning Points: High ßhCG in a male patient or a non-pregnant female suggests a paraneoplastic syndrome. In the case of persistently positive serum hCG, exclude immunoassay interference by doing the urine hCG as heterophilic antibodies are not present in the urine. Non-gestational choriocarcinoma is an extremely rare trophoblastic tumor and should be considered in young men presenting with gynaecomastia and high concentration of hCG with normal gonads. A high index of suspicion and extensive investigations are required to establish an early diagnosis of extra-gonadal choriocarcinoma. Early diagnosis is crucial to formulate optimal management strategy and to minimize widespread metastasis for best clinical outcome.

Gastrointestinal histoplasmosis in an HIV-infected patient living in a non-endemic area.

SUMMARY: A 36-year-old HIV-infected man presented with non-specific gastrointestinal symptoms and weight loss. Biopsy of the duodenum and an intra-abdominal lymph node showed Histoplasma capsulatum. The diagnosis of histoplasmosis was delayed as the presentation was initially ascribed to intercurrent enteric pathogens and the patient's lifetime travel history was not obtained.