Ogbole et al. Journal of Medical Case Reports 2011, 5:100 http://www.jmedicalcasereports.com/content/5/1/100 bilateral sixth and seventh cranial nerve palsies that were worse on the right side, impaired upward gaze and dys- diadochokinesia. His other systems were essentially nor- mal. A clinical impression of a left testicular tumor with right-sided sympathetic orchiopathy and intracranial metastases was made. The patient’s hematological and biomedical parameters were essentially normal, except for a raised erythrocyte sedimentation rate (52 mm/h). However, other complementary diagnostic tools such as serum lactic acid dehydrogenase (LCD) and b-human chorionic gonadotropin that are usually used [8] in such patients are not routinely available in our hospital. A scrotal ultrasound showed bilaterally enlarged testes, worse on the left, with a volume of 43.5 mL and 99.7 mL on the right and left, respectively. They showed a hetero- geneous echo pattern but appeared predominantly hypoechoic in nature. The left testis, in addition, showed multiple hypoechoic masses with scattered punctate cal- cifications (Figure 1). Doppler interrogation of both testes revealed an essentially moderate blood flow. There was no peritesticular fluid collection. An abdominal ultra- sound and chest radiograph showed no abnormality. However, an abdominal CT scan, which is necessary for proper staging, was not performed because of cost con- straints on the part of the patient, as our health system operates an out-of-pocket payment system. An ultra- sound impression of a left testicular tumor with micro- lithiasis was suggested. Contrast-enhanced cranial CT images showed multiple widespread punctate enhancing foci, with some showing Page 2 of 5 ring enhancement and minimal perilesional edema (Figure 2). The lesions involved both parietal lobes and extended to the vertex. An impression of multiple intra- cranial metastatic deposits, possibly from the known tes- ticular tumor, was made. The patient had undergone radical left orchidectomy and was administered intravenous ceftriaxone post- operatively. He was scheduled for radiotherapy while awaiting the histopathology report of the testicular spe- cimen. His clinical condition nonetheless deteriorated, as he developed right-sided hemiparesis and lost con- sciousness on the third postoperative day. Following a histopathologic diagnosis of chronic granulomatous dis- ease from tuberculosis (Figure 3), he was placed on anti- tuberculous therapy (ATT), including rifampicin (600 mg/daily), isoniazid (INH) 300 mg/daily, ethambutol (1.2 g/daily) and pyrazinamide (1.5 g/daily). He also received pyridoxine (vitamin B6) 25 mg/daily, which is routinely given along with isoniazid. His symptoms aba- ted, and he subsequently had sustained clinical progress with improved mental status and was discharged two weeks post-ATT for follow-up in the outpatient clinic. One week following discharge from our hospital, he developed a paradoxical response [9], with depressed level of consciousness, seizures and subsequent loss of consciousness. He was readmitted and managed with mannitol for six days as well as carbamazepine while continuing ATT. He regained consciousness and improved clinically. A cranial MRI scan obtained two weeks afterward showed a large T2 hyperintense area in the left temporal and frontal lobes with perilesional Figure 1 Ultrasound image showing enlarged left testis with diffuse hypoechoic masses and multiple foci of calcification within it. Figure 2 Axial computed tomographic image showing an enhancing intracranial focus.