Clinical Pediatrics

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Acute Scrotal Swelling in a Newborn With Bacteremia

H. Barrett Fromme, Lambda Msezane and Clare E. Close
CLIN PEDIATR 2008 47: 827 originally published online 19 June 2008
DOI: 10.1177/0009922808320702

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Acute Scrotal Swelling in a
Newborn With Bacteremia
H. Barrett Fromme, MD, Lambda Msezane, MD, and
Clare E. Close, MD
E
pididymitis is a rarely seen cause for scrotal
swelling in the newborn that often has a viral
etiology. Though prior case reports have rec-
ognized bacterial causes, including Haemophilus
influenza and Escherichia coli, in a preterm infant,
we report the case of a full-term neonate with epi-
didymitis secondary to hematogenously spread E coli.
Case Presentation
An 11-day-old male was admitted with decreased feed-
ing and rectal temperature of 100.3°F. He was a full-
term infant with a birth history significant for group B
Streptococcus-positive mother for which he received
ampicillin and gentamicin for 48 hours. Blood cul-
tures were negative, and he was discharged on the
third day of life. He continued to gain weight and feed
well until the presentation to the emergency room.
He was well appearing with mild jaundice but
otherwise normal including a normal genitourinary
examination. Labs demonstrated a white blood cell
count of 21.7, with 51% neutrophils, 12% bands,
17% lymphocytes, and 13% monocytes. Urinalysis
revealed a specific gravity of 1.002 and negative
nitrites and leukocyte esterase, with no white blood
cells or bacteria noted. Cerebral spinal fluid demon-
strated no pleocytosis with normal chemistries, and
cultures for all 3 fluids were sent.
He was started on ampicillin and cefotaxime and
admitted to the floor. Within 1 day the blood culture
grew E coli sensitive to ampicillin and ceftriaxone.
Urine and cerebrospinal fluid cultures were nega-
tive. The patient was treated with ampicillin and was
From the Sections of Pediatrics (HBF) and Surgery (LM, CEC),
the University of Chicago, Chicago, Illinois.
Address correspondence to: Helen Barrett Fromme, MD,
Section of Pediatrics, University of Chicago, 5721 S
Maryland Avenue, MC8016, Chicago, IL 60637; e-mail:
hfromme@peds.bsd.uchicago.edu.
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Clinical Pediatrics
Volume 47 Number 8
October 2008 827-828
© 2008 Sage Publications
10.1177/0009922808320702
http://clp.sagepub.com
hosted at
http://online.sagepub.com
clinically stable and afebrile throughout his course.
On hospital day 4, the patient was discharged to
complete a 10-day course of intramuscular ceftriax-
one daily as an outpatient.
The following day his primary care physician
noted him to be well appearing, afebrile, and active,
but there was left scrotal swelling with mild discom-
fort on palpation. The scrotum was not discolored
and did not transilluminate. An emergent scrotal
ultrasound demonstrated areas of heterogeneously
increased and decreased echogenicity with a complex
hydrocele and enlarged epididymis. Doppler showed
increased flow around the left testis, which measured
1.0 cm × 0.8 cm × 0.8 cm. The right testis was nor-
mal in appearance. A radiologic diagnosis of chronic
left testicular torsion was made, and the patient was
scheduled for urologic surgery the following day.
At surgery, the left spermatic cord showed no evi-
dence of torsion, but both the epididymis and the
cord had significant inflammation. The testis was of
normal size and pink, with an inflammatory peel
around the entire testis. As the testis was high riding
on initial exploration, an orchidopexy was performed.
The pathology of the inflammatory peel confirmed
the presence of necrosis and inflammatory debris,
leading to a final diagnosis of left epididymitis.
Postoperatively the patient underwent renal ultra-
sound (RUS) and voiding cystoureterogram (VCUG).
The RUS revealed bilateral grade 1 hydronephrosis
without evidence of a duplicated system or ectopic
ureter. The VCUG was negative. A repeat RUS was
obtained 1 month later with resolution of the
hydronephrosis. The patient has been doing well since.
Discussion
The differential diagnosis of pediatric scrotal swelling
is broad, including testicular torsion, incarcerated her-
nia, epididymitis, orchitis, hydrocele, varicocele, and
vasculitis. The 3 most common causes of acute
827
828 Clinical Pediatrics / Vol. 47, No. 8, October 2008
swelling are testicular torsion, epididymo-orchitis, and
torsion of the testicular appendage.1 In infants, how-
ever, prevalence of these diagnoses varies, with epi-
didymitis becoming far less common, and the majority
being identified as torsion or torsed appendix. Though
in older children testicular torsion is described as
exceedingly painful, torsion in the infant most often
does not cause any distress or discomfort. Primary
signs of neonatal torsion are swelling (often unilat-
eral), bluish discoloration of the scrotum, and firm-
ness to palpation. Due to the concerns of possible
torsion, acute swelling in the newborn scrotum that is
firm and does not transilluminate requires emergent
ultrasound evaluation and likely surgical exploration to
determine the cause. Seventy percent of all neonatal
torsion is prenatal and, thus, has a low salvage rate
with emergency surgery.2 However, exploratory surgery
should be performed to rule out a tumor and fixate an
unaffected contralateral testicle.3 It is often during
this exploration that the alternate diagnoses are con-
firmed. The literature demonstrates other rare causes
of acute scrotal swelling caused by acute perforated
appendix,4 neonatal adrenal hemorrhage,5 scrotal
hematoma,6 and epididymitis.
Epididymitis and/or epididymo-orchitis are uncom-
mon in the pediatric population in general and rare in
the neonatal population.7 The etiology can be viral,
bacterial, secondary to urogenital abnormalities, or
secondary to reflux of sterile urine into ejaculatory
ducts.8 Patients under 2 years of age with epididymitis
are far more likely to have anatomic abnormalities.7,8
It has also been demonstrated that urogenital abnor-
malities are often seen in patients with bacterial
causes.3 Due to this concern, most investigators will
evaluate for potential anomalies in neonates and those
with positive urine or bacterial cultures. This work-up
should include VCUG and RUS.7
In those patients who do not have a demonstrable
anatomic anomaly, a proposed etiology is hematogenous
spread of systemic bacterial or viral infection to the epi-
didymis. Case reports have implicated H influenzae,
Salmonella, and, in 1 preterm infant, E coli septicemia
leading to epididymitis.9 E coli sepsis has been reported
as the cause of scrotal abscess in a newborn as well.10
Determining that the route is hematogenous requires
exclusion of urinary tract infection, and the presence of
positive blood cultures suggests such an etiology. In the
case of an infected hydrocele or abscess, aspirated cul-
tures can confirm the same bacteria as in the blood.
Excluding the few reported cases of confirmed
hematogenous spread, the etiology is often difficult to
demonstrate and most cases are declared idiopathic.
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Though this discussion has been based on the
identification of scrotal swelling prior to detection of
any other abnormalities, it is important to consider
the possible complication of epididymitis subse-
quent to neonatal infection, including E coli. Our
patient developed symptoms 5 days after appropriate
therapy was begun for the bacteremia, which we
consider to be secondary to the delay in inflamma-
tory changes to the epididymis. We confirmed no
structural abnormality with VCUG and RUS, thus
confirming the diagnosis of hematogenous spread.
After therapy the patient continued to do very well
and has had no further symptoms.
In conclusion, acute scrotal swelling in the
neonate is a serious symptom that must be investi-
gated rapidly with ultrasound and often exploratory
surgery. Though rare, neonatal epididymitis must be
considered in any patient with these symptoms,
especially in the setting of bacteremia or urinary
tract infection. Early initiation of antibiotics for the
infectious etiology is the ultimate therapy, but it is
important to rule out acutely damaging causes, such
as torsion and incarcerated hernia.
References
1. McAndrew HF, Pemberton R, Kikiros CS, Gollow I. The
incidence and investigation of acute scrotal problems in
children. Pediatr Surg Int. 2002;18:435-437.
2. Cuckow PM, Frank JD. Torsion of the testis. BJU Int.
2000;86:349-353.
3. Kaplan GW. Scrotal swelling in children. Pediatr Rev.
2000;21:311-314.
4. Nagel P. Scrotal swelling as the presenting symptom of
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5. Duman N, Oren H, Gulcan H, Kumral A, Olguner M,
Ozkan H. Scrotal hematoma due to neonatal adrenal
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