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• W2069138840 abstract "Acute scrotal swelling is usually secondary to torsion of the spermatic cord or testicular appendages, or to epididymo-orchitis.1, 2 A less common possibility that should be included in the differential diagnosis is an infected scrotum.3 We report a 24-day-old male newborn with an acute scrotal swelling resulting from scrotal infection caused by Salmonella enteritidis. We review five additional cases of genital manifestation of salmonellosis in infants <3 months of age. Case report. A 24-day-old male newborn, the product of an uneventful 40-week pregnancy and routine vaginal delivery, was in good health after delivery. On the day of admission he developed fever and swelling of the right hemiscrotum. He vomited twice but continued to take formula adequately. There had been no recent change in his regular pattern of two to three normal bowel movements daily. Physical examination revealed an alert 3900-g male neonate in good general condition. The temperature was 38.5°C and the pulse was 156 beats/min. The abdomen was soft, with normal bowel sounds. The right scrotum was swollen and transilluminated light. The infant was not irritable during examination. The left scrotum was normal and the remainder of the physical examination was unremarkable. A complete blood count revealed the hemoglobin and hematocrit to be 10.3 mg/dl and 28.5%, respectively, and the white blood cell count was 8100/mm3, with 63% segmented neutrophils, 29% lymphocytes and 8% monocytes. Urinalysis revealed 50 to 80 red blood cells and 1 to 3 white blood cells per high power field but was otherwise normal. Cerebrospinal fluid (CSF) contained 5 white blood cells and 144 red blood cells/mm3, protein of 45 mg/dl and glucose of 68 mg/dl. Serum glucose was 86 mg/dl. A Gram-stained smear of the CSF was negative. C-reactive protein was elevated (58.6 mg/dl; normal, <5 mg/dl). Chest radiograph as well as serum urea, creatinine and electrolytes were normal. Cultures were obtained from blood, urine, CSF and stool. A tentative diagnosis of testicular torsion was made and consultation with a pediatric surgeon was obtained. Right sided hydrocele was the working diagnosis and ampicillin and gentamicin were given intravenously for possible infection. On the second hospital day the infant became afebrile and repeated urinalysis was normal. Abdominal sonography did not reveal abnormal findings. However, on the next day the right scrotum was tender, tense and slightly warm and the infant was irritable. A 2- by 3-cm mass was palpable within the scrotum, which was indistinguishable from the testis and epididymis. The 99mTc radionuclide testicular scan revealed symmetrical blood flow in both hemiscrota. There was no evidence of testicular torsion. A color doppler ultrasonography examination found a hypoechoic area over the right testis. Blood flow was absent in this region, but normal testicular blood flow was confirmed. Because the testicular torsion remained a serious consideration, the infant was taken to the operating room for scrotal exploration on the fourth hospital day. The right scrotal sac was filled with pus and fibrin. After evacuation the testis appeared to be normal and there was no evidence of torsion of the testis or its appendix. The epididymis was edematous and the scrotal wall was very thick. A pus culture was performed at the same time. A Penrose drain was placed and the scrotum was closed. Postoperatively the infant remained afebrile and continued to eat well. Cultures of the pus yielded S. enteritidis; anaerobic cultures yielded no growth. Urine, blood and CSF cultures were sterile but subsequent stool culture grew S. enteritidis, which had an antibiogram identical with that of the isolate from the pus. The organism was susceptible to ampicillin and gentamicin. Intravenous antibiotic therapy with ampicillin and gentamicin was continued for 8 days, after which a 10-day course of oral amoxicillin was prescribed. At follow-up 5 months later, the right testis was palpably normal in shape and size when compared to the left testis. Discussion.Salmonella infection in the genital tract is rare. In a review that included more than 700 extraintestinal manifestations of Salmonella infections, only 12 cases of orchitis or epididymitis were described (1.4%).4 In the age group of 3 months or younger, we could find only 5 cases in the medical literature (Table 1). Our case and these 5 patients all underwent operative intervention. Among them 2 were suspected to have incarcerated inguinal hernia,5, 6 2 patients had a tentative diagnosis of testicular torsion,9 1 had cellulitis of the scrotum7 and the last case was because of acute scrotal swelling.8 Scrotal infection is a rare but important differential diagnosis in infants with acute scrotal swelling.TABLE 1: Clinical details of six infants with Salmonella scrotal infection The source of the Salmonella and route of infection in our newborn are not clear. It is of interest that no symptoms of gastroenteritis were present in our patient or his family, despite the positive stool culture. Careful investigation of the newborn nurseries revealed no known source of Salmonella. A probable route of infection for Salmonella scrotal abscess is hematogenous. Although the blood culture was negative in our patient, bacteremia could have been intermittent. The other explanation for an infected scrotum is seeding from an intraperitoneal source via a patent processus vaginalis. The presence of a patent processus vaginalis may be reflected by scrotal intraabdominal pathology.10-12 In our case the early age and the presence of a hydrocele would tend to suggest the infection occurred through a patent processus vaginalis, resulting in collection of pus in the tunica vaginalis and causing an infected hydrocele or pyocele. In extremely rare cases infectious agents may reach the testis and epididymis through the skin of the scrotum.13 Whether the Salmonella pyocele was from stools soiling the perineum and genitalia in our case is speculative. Although testicular torsion and incarcerated inguinal hernia should be ruled out first in infants with a swelling and tender hemiscrotum, scrotal abscess must be considered. Radionuclide scrotal imaging can be helpful for differentiating torsion of the spermatic cord from other intrascrotal lesions. Color doppler sonography is a more readily available and convenient tool that bases its effectiveness on the principle of decreased or absent testicular blood flow seen with spermatic cord torsion. In all previously reported cases of Salmonella testicular abscess, surgical incision and drainage in addition to intravenous antibiotic therapy for 10 to 14 days were necessary to eradicate the infection. Chung-Bin Huang, M.D. Jiin-Haur Chuang, M.D. Departments of Pediatrics (CBH) and Pediatric Surgery (JHC); Chang Gung Children's Hospital at Kaohsiung and Chang Gung Medical College; Kaohsiung, Taiwan" @default.
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• W2069138840 title "ACUTE SCROTAL INFLAMMATION CAUSED BY SALMONELLA IN YOUNG INFANTS" @default.
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