Letters to the Editor

Abstract

21 November 2008 Dear Editor, NEONATAL TESTICULAR TORSION OR NOT? Neonatal adrenal haemorrhage commonly manifests with anaemia, jaundice, vomiting and abdominal mass. It may be diagnosed incidentally if the haemorrhage is not significant. Neonatal adrenal haemorrhage can present as scrotal discoloration and swelling mimicking acute scrotum. Awareness of this clinical association helps in avoiding unnecessary neonatal scrotal exploration. Baby B presented on the 11th day of life with scrotal swelling and discoloration. He was a full-term male baby weighing 3485 g, born of normal vaginal delivery with a short duration of labour due to rapid second stage. He developed jaundice on the second day of life. His unconjugated bilirubin was 383 µmol/L. His jaundice was unresponsive to phototherapy, and his gamma-glutamyl transferase levels were 806 IU/L. Hepatitis and Coomb's serology was negative. He was noted to have a right scrotal mass and scrotal discoloration on the right side. The whole testis felt to be enlarged and firm with an odd shape. There were no abdominal masses palpable. The differentials considered were perinatal torsion and testicular tumour. He was otherwise well, tolerating feeds without vomiting. Work-up for jaundice revealed reticulocytosis and falling haemoglobin (167–155 g/L) and haematocrit (0.486–0.448 L/L) over 3 days. This prompted us to look for an intra-abdominal bleed as cause of jaundice and scrotal swelling. He had a scrotal and abdominal ultrasound that revealed a scrotal haematoma and an avascular right adrenal mass suggestive of adrenal haemorrhage (Fig. 1). The testis was normal. Laboratory tests for urinary catecholamines were within normal limits. Ultrasound showing 4-cm adrenal mass with central necrosis. The patient was managed conservatively with a plan to monitor the mass with regular ultrasounds. Follow-up ultrasound showed decrease in the size of the adrenal haemorrhage with liquefaction. In 12 weeks time, the mass was only 1 cm in size (from the initial size of 4 cm) (Fig. 2). Follow-up ultrasound showing decrease in size from the initial scan. Neonatal adrenal haemorrhage occurs in about 0.2% of neonates.1 It is associated with hypoxia, birth trauma, but is also known to be spontaneous. Adrenal haemorrhages are more common in males and on the right side. Clinical features depend on the amount of bleeding. The common presentation is anaemia, jaundice, abdominal distension and abdominal mass. It can be an incidental finding in asymptomatic babies.1 Twenty-two cases of scrotal haematoma as an association with adrenal haemorrhage have been reported in the literature. Nine (41%) have had surgical scrotal exploration to exclude torsion as it may be difficult to feel the testis separate from the scrotal haematoma or haemorrhage could have tracked down a patent processus around the testis. The reason for delayed presentation in our case could be time taken to track down the retroperitoneum. The rest of the cases had non-surgical management after further evaluation.2 One of the cases reported in the literature developed disseminated intravascular coagulation after having an unnecessary scrotal exploration. It was detected to have adrenal haemorrhage by a post-operative abdominal ultrasound scan.3 It is emphasised that an awareness of the condition and a scrotal/abdominal ultrasound helps make the diagnosis and prevent an unnecessary operation. This association should be kept in mind in the clinical scenario of neonatal anaemia, jaundice and acute discoloured scrotum (scrotal haematoma). On rare occasions, computed tomography may be needed to confirm the diagnosis.4