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Adrenal Haemorrhage Associated with Scrotal Swelling in a Neonate |
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Rakesh Kumar, Sanober Wasim, Yasir Ahmed Lone, Girish Gupta, Talha Rehman 1. Assistant Professor, Department of Neonatology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India. 2. Associate Professor, Department of Neonatology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India. 3. Associate Professor, Department of Paediatric Surgery, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India. 4. Professor, Department of Neonatology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India. 5. Fellow, Department of Neonatology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India. |
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Correspondence Address : Rakesh Kumar, Department of Neonatology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India. E-mail: drrakesh99@yahoo.com |
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| ABSTRACT |  | ||||||||||||||||||||||||||||||||||||
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| Keywords : Differential diagnosis, Testicular torsion, Ultrasonography | |||||||||||||||||||||||||||||||||||||
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DOI and Others :
DOI: 10.7860/IJNMR/2022/53625.2336
Date of Submission: Jan 01, 2022 Date of Peer Review: Feb 21, 2022 Date of Acceptance: Mar 02, 2022 Date of Publishing: Jun 30, 2022 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was informed consent obtained from the subjects involved in the study? Yes (from parents) • For any images presented appropriate consent has been obtained from the subjects. Yes (from Parents) PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: |
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| Case Report |
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A male neonate was born to 22-year-old primigravida mother, via a lower segment caesarean section, at 35 weeks of gestation. The birth weight of the baby was 1270 grams. Antenatal history was suggestive of oligohydramnios, and severe intrauterine growth restriction. The baby did not cry after birth, and was resuscitated. The Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score was 6, 8 and 9 at 1, 5 and 10 minutes, respectively. He developed respiratory distress soon after birth, was intubated and shifted to Neonatal Intensive Care Unit (NICU). He was nursed under a radiant warmer, mechanical ventilation {Mode Pressure Support Ventilation (PSV), Pressure 10, Positive End-Expiratory Pressure (PEEP) 6, Fraction of Inspired Oxygen (FiO2) 40%} was started, and Intravenous (i.v.) fluids were given. Investigations revealed a deranged coagulation status {Prothrombin time of 19.5 seconds, International Normalized Ratio (INR) of 1.40, activated Partial Thromboplastin Time (aPTT) 71 seconds}. Injection vitamin K 1.0 mg i.v. was given and Fresh Frozen Plasma (FFP) was also transfused (10 ml/kg). Scrotal swelling with discolouration of scrotum was observed at 16 hours after birth. Bluish discolouration of the right inguinal region was also observed, which gradually increased to involve the abdomen on the right side (Table/Fig 1). Inhouse Ultrasonography (USG) was not available at the time limiting evaluation of the scrotum. Considering the urgency of salvaging testes, scrotal exploration was done within two hours. The entire scrotal sac was filled with blood and blood clots. Bilateral testes were healthy but oedematous. The collected blood was drained and bilateral testicular fixation was done, after attaining haemostasis (Table/Fig 2), (Table/Fig 3), (Table/Fig 4). One unit of FFP was transfused postexploration. Paracetamol drops were given for analgesia. The baby was then extubated 24 hours after surgery, and was put on bubble Continuous Positive Airway Pressure (CPAP) support. An ultrasonographic assessment of the abdomen was done on the third day of life, which revealed a heterogeneously hyperechoic area measuring approximately 1.75×1.7×1.2 cm, with 1.8 cc of volume in the right adrenal, which was suggestive of right adrenal haematoma (Table/Fig 5). A diagnosis of scrotal haematoma associated with adrenal haemorrhage was thus made, and it was managed conservatively. There were no features of adrenal dysfunction such as hypotension, hypoglycaemia, or vomiting. A repeat ultrasonographic assessment, at 14 days of life, showed the right adrenal gland was bulky measuring approximately 1.7×1×0.9 cm with cystic area within. The baby was discharged on day 18 of life with advise about feeding and on multivitamin and calcium supplements. He has been regularly followed-up and at the last visit he had normal adrenal glands and testis and he was three months old. | |||||||||||||||||||||||||||||||||||||
| Discussion |
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Acute scrotal swelling in a neonate is a condition which requires prompt diagnosis and management to salvage the underlying testicular tissue if involved. It may be caused by conditions involving the testis, epididymis or the scrotal sac (1),(2). Neonatal adrenal haemorrhage may sometimes present as inguinoscrotal swelling, and may require immediate surgical exploration as they may mimic testicular torsion or strangulated hernia (3),(4). Ultrasonography is the imaging modality of choice as it provides a non invasive assessment of the scrotum and guides for the further medical and surgical management (5). Acute scrotal haematoma in the neonatal period is a rare condition, and exact incidence remains unknown. Though there are many causes which may result in scrotal haematoma, time is of essence as testicular torsion is one of the differentials which needs urgent surgical correction (6). Doppler ultrasonography has gradually replaced the need of prompt surgical exploration of scrotum and can differentiate conditions such as testicular torsion, scrotal or testicular oedema, inguinal hernia, testicular trauma, or adrenal haemorrhage in an acute scrotum (7). Ultrasonography along with doppler though an easy aid for diagnosis of testicular torsion may not be available. It is better to explore the testis to save the gonad if USG is not available (8). In this case, as there was unavailability of USG assessment, testicular exploration was done. Gkantseva-Patsoura S et al., reported a case of scrotal haematoma, the exact aetiology of which remained elusive. The neonate was managed conservatively with regular ultrasonographic assessment of scrotum (9). Thus, one should be aware that even after a complete evaluation, exact aetiology in some of the cases may remain obscure. In the index case, baby scrotal haematoma may have resulted from coagulopathy. Adrenal haemorrhage has been reported to be the second most common cause of haemoperitoneum in neonates with the incidence of 2/1000 births (10). The causes can be birth asphyxia, trauma during delivery or haemorrhagic disorders (11). The index baby had birth asphyxia and coagulopathy which may have resulted in adrenal haemorrhage. Adrenal haemorrhage is common on the right side with about 10 percent cases being bilateral (12). Most of the times it remains confined within the capsule but breach of the capsule may result in spread of bleed to retroperitoneum and rarely into the peritoneal cavity (13). In two cases reported by Kouame YGS et al., adrenal haemorrhage presented as acute scrotum, and one of the neonate required surgical exploration of scrotum due to poor testicular vascularity. The authors concluded that serial ultrasonographic observation was a good treatment strategy in adrenal haemorrhage (14). The scrotal discolouration is also a sign of testicular torsion. Though considered a rare entity, it is now reported more frequently. Most of the cases of testicular torsion occur before birth and only 20% of testicular torsion is thought to occur postnatally (15). Abbas TO and Ali M reported a case of neonate presenting with bluish discolouration of the unilateral scrotum, which was managed surgically. They concluded that an immediate surgical exploration should be considered in suspected bilateral neonatal testicular torsion (16). In the index case, the baby presented with bluish discolouration of the scrotum and as no radiological evaluation was possible at the time it was decided to explore the scrotum. If testicular torsion is not the cause of haemoscrotum most of the time, it can be managed conservatively. The surgical exploration is required only when the conservative protocol fails or the haematoma is infected (17). The adrenal haemorrhage, in the present case, was managed conservatively with regular clinical and ultrasonological evaluations. The patient so far has showed a good outcome. In the index case, adrenal haemorrhage can be an association and not the causation with haemoscrotum as the capsule of adrenal gland was not breached at the time of first ultrasonographic assessment. Considering the frequent association of scrotal haematoma with adrenal haemorrhage ultrasonography of the abdomen and evaluation of adrenals should always be considered in cases of scrotal haematoma. | |||||||||||||||||||||||||||||||||||||
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Case report
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