Scrotal Rash in an Elderly Man

Winston W. Tan, MD; Matthew S. Soberano, DO; A. Toledo, DO; Matthew Clarence Tan

Disclosures

September 30, 2015

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.

Background

A 77-year-old man who was previously diagnosed with prostate cancer presents with a scrotal rash (such as the one illustrated in Figure 1). Approximately 10 years ago, a prostate-specific antigen (PSA) elevation of 15 ng/dL was detected. He had a biopsy that revealed prostate adenocarcinoma with high-grade intraepithelial neoplasia. He had a radical prostatectomy. Final pathology revealed a Gleason score of 4 + 4 = 8. The tumor was confined within the prostatic capsule. The seminal vesicle was negative for involvement, and the margins were free, making him stage T2NxMx.

Figure 1.

The patient had undetectable PSA and no evidence of disease for more than a decade. When his PSA levels began to rise to 25 ng/dL, he was started on leuprolide (Lupron®); his PSA level became undetectable. Subsequently, he was placed on intermittent hormone treatment with leuprolide at 22.5 mg every 3 months if his PSA was above 5 ng/dL. Approximately 2 years ago, he developed bone metastasis to his sternum, spine, and pelvis. He became castrate resistant and also had congestive heart failure secondary to severe mitral regurgitation.

He presented for a consult due to congestive heart failure and a scrotal rash that had been present more than 3 months. The rash is erythematous, maculopapular, nonpruritic, and nontender. He has no palpable testicular mass. The patient's history is significant for genital edema secondary to congestive heart failure.

His family history is positive for congestive heart failure and coronary artery disease in his father and mother. He has a history of 30 pack-years of smoking, and he is married. He is also on the following medications:

  • Furosemide (Lasix®)—40 mg orally (PO) daily

  • Lisinopril (Prinivil®)—10 mg PO daily

  • Aspirin (Ecotrin®)—325 mg/tab PO daily

  • Potassium chloride (K-tab®)—20 mEq daily

  • Leuprolide—30 mg intramuscularly every 4 months

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