QUEST FOR THE DIAGNOSIS

Neonatal scrotal discoloration and swelling(Discussion and Diagnosis)

Anastasia Oikonomou (aoikonom@med.duth.gr)1, Katerina Kampouri2, Stefanos Gardikis2, Marianna Skordala3,Georgios Vaos2 and Panagiotis Prassopoulos1

1.Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece2.Department of Pediatric Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece3.Department of Neonatology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece

CorrespondenceAnastasia Oikonomou, Department of Radiology,University Hospital of Alexandroupolis,Democritus University of Thrace, Dragana, 68100Alexandroupolis, Greece.Tel: +30 25510 76803 |Fax: +30 25510 30473 |Email: aoikonom@med.duth.gr

Received14 November 2011; revised 26 March 2012;accepted 4 April 2012.

DOI:10.1111/j.1651-2227.2012.02703.x

The Case Presentation can be found page 799DISCUSSION AND DIAGNOSISAbdominal ultrasound revealed a rather well-defined heter-ogeneous, space-occupying lesion in the anatomic region ofthe right adrenal. This lesion retained the triangular shapeof the adrenal exhibiting intermingled anechoic, hypoecho-ic and hyperechoic areas surrounded by a hypoechoic halo(Fig. 1). No blood flow was detected within the lesion, andnormal parenchyma of the right adrenal was not seen. Leftadrenal, kidneys, liver and pancreas were within normallimits. Adrenal haemorrhage and extension to the scrotumvia the retroperitoneal space were considered as the mostprobable diagnosis, and the possibilities of abscess andtumour were considered less likely.

An abdominal MRI was performed to exclude possibleunderlying pathology of the right adrenal. MRI revealed aheterogeneous lesion retaining the triangular shape of theadrenal gland, with predominantly high signal intensity onT1-weighted images and significant blooming artefact ingradient-echo images confirming the diagnosis of adrenalhaemorrhage (Fig. 2). Extension of haemorrhage along theretroperitoneal space was noticed. No underlying mass wasseen.

The patient was managed conservatively and was dis-charged after 1 week. Monitoring of the adrenal hematomawith ultrasonography revealed a gradual decrease in sizewith the residual hematoma measuring only 0.66 · 0.67 cmin size on the 6-week follow-up US examination.

Scrotal hematoma as a consequence of adrenal haemor-rhage has been very scarcely described in the literature and

– to the best of our knowledge – this is the first report of thisrare association documented by both ultrasound and MRIevaluation. In cases of abundant adrenal haemorrhage –where the blood cannot be contained into an intact adrenalcapsule – it may dissect along the retroperitoneum into thescrotum through an open processus vaginalis. The latter isreported to be open in 90% of neonates (1). Clinical mani-festations include discoloration of the scrotum and ⁄ oringuinal and perineal areas, scrotal hematoma and painfulor painless acute swelling of the hemiscrotum and groin (2).Differential diagnosis of scrotal discoloration and swellingincludes traumatic hematoma, hydrocele, torsion of the tes-tes, orchitis, scrotal or testicular oedema, inguinal hernia,meconium peritonitis, hematocele and testicular tumour(1,3). US of the scrotum could assist clinical differentialdiagnosis; it readily shows scrotal effusions and confirmsthe viability and vascularity of the testicles excluding thepossibility of testicular torsion (1).

Neonatal adrenal haemorrhage is an uncommon entitywith a reported incidence of 0.05–1.4% (1). It is assumedthat the adrenal gland of the neonate is vulnerable to vascu-lar damage and haemorrhage because of its relatively largesize (4). It usually occurs at the right adrenal – as in our case– probably due to the direct drainage of the right adrenalvein to the inferior vena cava, while in 10% of the cases, itoccurs bilaterally (4). Predisposing factors are difficult deliv-ery, preterm gestation, increased birth weight, perinatalhypoxia, asphyxia and renal vein thrombosis (5). Clinicalmanifestations may vary from completely asymptomatic torarely severe intraabdominal life-threatening haemorrhage.

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Occasionally, there may be hemolysis and jaundice or per-sistent anaemia and rarely an abdominal mass is palpated(4,5). In the differential diagnosis of an adrenal hematomaunderlying tumours or tumour-like lesions of the adrenalgland causing haemorrhage have to be excluded such asneuroblastoma, abscess and even more rarely Wilms’tumour (1). US demonstrates the enlargement of the glandwith mixed echogenicity and the loss of central echogenicstripe in adrenal haemorrhage. However, a tumour compli-cated by haemorrhage may also have a similar appearancewith adrenal haemorrhage on US at initial presentation.MRI of the adrenal glands may have a role in differentiatingunderlying tumours and especially cystic neuroblastomathat could also be complicated by haemorrhage. T1 hyperin-tensity and blooming artefact in gradient-echo images con-firm the presence of haemorrhage as in the presented case,while the absence of gadolinium enhancing tissue withinthe ‘hematoma’ excludes the presence of an underlyingtumour (5,6). Measurement of vanillylmandelic acid con-centration in 24-h specimen can also facilitate differentialdiagnosis (2).

In most cases, the adrenal haemorrhage is self-limitedand it is treated conservatively. Follow-up US examina-tions will not only suggest the correct diagnosis but willestablish the final diagnosis by demonstrating gradualdecrease in size of the lesion, as in our case usually within1 or 2 weeks (1,5). In case of a large hematoma, drainagemay be deemed necessary. Surgery is saved for the rarepossibility of hypovolemic shock or in case of an abscesscomplicating the hematoma. Adrenal insufficiency is a raremanifestation that responds well to steroid replacementtherapy (2).

In conclusion, adrenal haemorrhage should be listed inthe differential diagnosis of causes of bluish discoloration ofthe scrotum in neonates. Combination of scrotal andabdominal ultrasound seems to be the modality of choicefor the investigation of an adrenal hematoma associatedwith hemiscrotal discoloration and swelling. The diagnosiscan be established by follow-up ultrasound, either alone, or

in combination with MRI. MRI can support the diagnosisand exclude the presence of a cystic neuroblastoma thatmay also be manifested by adrenal haemorrhage extendingto the scrotum. Imaging has a pivotal role in the diagnosisand monitoring of patients and in avoiding unnecessaryoperations and possible sacrifice of a healthy testicle.

DIAGNOSISAdrenal haemorrhage and extension to the scrotum via theretroperitoneal space.

Figure 1 Axial ultrasound image of the abdomen demon-strating a triangular-shaped ‘mass’ with anechoic and hy-perechoic areas surrounded by a hypoechoic band.

Figure 2 MRI of the abdomen shows a well-definedadreniform-shaped mass at the anatomic area of the rightadrenal with high signal intensity on T1-weighted axialimage confirming the haemorrhagic content of the lesion.

References

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2. Goncalves R, Abuabara A, Abuabara RFF, Feron CA. Scrotalhematoma as a sign of adrenal hemorrhage in newborns. SaoPaulo Med J 2011; 129: 113–5.

3. Diamond DA, Borer JG, Peters CA, Cilento BG Jr, Sorcini A,Kaefer M, et al. Neonatal scrotal hematoma: mimicker of neo-natal testicular torsion. BJU Int 2003; 91: 675–7.

4. Qureshi UA, Ahmad N, Rasool A, Choh S. Neonatal adrenalhemorrhage presenting as late onset neonatal jaundice. J IndianAssoc Pediatr Surg 2009; 14: 221–3.

5. Kawashima A, Sandler KM, Randy DE, Takahashi N, Roubi-doux MA, Goldman SM, et al. Imaging of nontraumatic hemor-rhage of the adrenal gland. Radiographics 1999; 19: 949–63.

6. Gavrilova-Jordan LP, Edmister WB, Farrell MA, Watson WJ.Spontaneous adrenal hemorrhage during pregnancy: a review ofthe literature and a case report of successful conservative man-agement. Obstet Gynecol Surv 2005; 60: 191–5.

Oikonomou et al. Neonatal scrotal discoloration and swelling

ª2012 The Author(s)/Acta Pædiatrica ª2012 Foundation Acta Pædiatrica 2012 101, pp. 888–889 889