Pulmonary embolism as the first manifestation of metastatic testicular cancer

Testicular cancer is a rare disease, corresponding to 1% of malignant tumors, and its association with pulmonary embolism is equally uncommon. A 23-year-old male presented to the emergency department with symptoms of dyspnea and chest pain for 2 days. Patient was hemodynamically stable and afebrile, although tachypnea and hypoxemia were evident. Cardiac ultrasound was performed and revealed right ventricular dilatation and computed angiotomography confirmed bilateral pulmonary embolism as well as the presence of multiple pulmonary nodules suggestive of cannonball metastasis, a voluminous liver mass and an extensive retroperitoneal conglomerate. After a complete anamnesis and physical evaluation, a painless left testicular nodule was identified, and orchidectomy was performed six days after starting anticoagulation. Histology revealed a classic seminoma and chemotherapy was started immediately. The present study reports pulmonary embolism as an atypical first manifestation of a testicular cancer. Considering the age and the extent of the oncological disease, the hypothesis of a primary testicular cancer must be considered, and a thorough examination should be performed. Early diagnosis and prompt institution of pulmonary embolism treatment, as well as chemotherapy, provide a better prognosis for these patients.