Mixed Anaerobic and Aerobic Testicular Abscess in a Neonate

Daljeet Singh, Sourabh Dutta, Praveen Kumar and Anil Narang

Neonatology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh-160 012, India

Abstract. A premature baby developed a testicular abscess on day 28 of life. The pus aspirated from the abscess grew a mixture of beta hemolytic Streptococcus and a Bacteroides species. The source of this infection could not be identified. The baby improved on antibiotic therapy. This is the first reported case of a polymicrobial testicular infection involving an anaerobe in a neonate. The relevant literature is reviewed. [Indian J Pedlatr 2001; 68 (6) : 561-562]

Key words : Testicular abscess; Serotal swelling; Infection

Testicular abscess is a rare condition in neonates. 1 We describe here a newborn infant who developed a testicular abscess due to a mixed anaerobic and aerobic infection, that was successfully treated.

CASE REPORT

A male baby, with a birth weight of 2000 grams, was born at 34 weeks gestation to a third gravida mother by normal vaginal delivery. He developed KlebsieUa pneumoniae septicemia on day 11 of life. The baby was treated with intravenous Ciprofloxacin and Amikacin for 2 weeks and he recovered from this episode. The baby was noted to develop a firm, indurated swelling in the left scrotum from day 28 of life which gradually increased in size to 1.5 cms x 2 cms over the next week. The corresponding testis and epididymis could not be felt separately from it. The swelling was tender, but not erythematous or warm to palpation. It was neither transilluminable nor reducible. There were no systemic signs of infection. There was no history of local trauma; intestinal obstruction, perforation, peritonitis; or intermittent scrotal swelling in the first three weeks of life. His urinary bladder had never been catheterised. Ultrasonography showed that the left testis was enlarged, it had a heterogenous echotexture with multiple hypoechoic areas. The right testis was normal and retractile. The abdominal ultrasound showed a structurally normal urinary system and intestines. No calcifications or free fluid was seen in the abdominal

Reprint requests : Dr. Sourabh Dutta, Assistant Professor, Departr, tent of Pediatrics, PGIMER, Chandigarh-160 012, India. E-mail : sourabh@chl.dot.net.in

cavity. The urinalysis and urine culture did not reveal any evidence of urinary tract infection. Needle aspiration from the testicular swelling revealed 5 ml frank yellow pus. The pus culture grew a mixture of aerobic 15 hemolytic Streptococcus and Bacteroides species. The blood culture was sterile. Clinically and radiologically there was no evidence of an abscess or localised infection anywhere else in the body. The body was treated with Crystalline Penicillin and Amikacin for two weeks with complete regression of the swelling. A repeat ultrasound at the end of two weeks showed resolution of the abscess. There has been no recurrence of the scrotal swelling on a follow-up of 3 months.

DISCUSSION

Scrotal masses are not rare in neonates) The differential diagnosis includes incarcerated or strangulated hermia, hydrocele, testicular tumors, calcified meconium within the scrotum, traumatic hematoma, testicular torsion, epididymitis, orchitis and very rarely testicular abscess. 2~ Irreducible hernias and testicular torsion need early recognition for urgent surgical intervention.

The index patient did not have a palpable scrotal mass at birth. It was noticed, as a gradually increasing scrotal swelling, after the baby had been adequately treated for neonatal sepsis due to Klebsiella. As the swelling was tender and the baby was otherwise well, the most likely clinical diagnosis at that time was testicular torsion, traumatic hematoma or obstructed inguinal hermih. These diagnoses were negated on the

Indian Journal of Pediatrics, Volume 68--June, 2001 561

Daljeet Singh et al

ultrasound picture, which suggested the possibility of an abscess, and which was subsequently confirmed by aspirating pus.

The mixed g rowth of aerobic ~-hemoly t ic Streptococcus and a Bacteroides species f rom the aspirated material was, however, unexpected. It is well know that aerobes facilitate establishment of anaerobic infection by destroying previously well-oxygenated tissue. Polymicrobial infection with synergy between aerobic and anaerobic organisms are known to occur in var ious par ts of the body. Both Bacteroides and Streptococcus have been impl ica ted in local ized suppurative disease of the female genital tract?

Proximity of the infection to a mucoscal surface colonized with anaerobic bacteria (such as oropharynx, intestinal and genitourinary tract) is one of the various clues to a p r e s u m p t i v e d iagnosis of anaerobic infection. 4 In this patient however, it is difficult to explain how the anaerobic organisms reached the testis to create an abscess. There was no evidence of a breech of a mucosal barr ier at any t ime after birth, both clinically and radiologically. A hematogenous spread seems unlikely because the blood culture was sterile and there was no focus of infection anywhere else in the body. It is also unlikely to have been acquired from the ma te rna l geni tal t ract at bir th, because it manifested only on day 28 of life. There were also no external lesions on the scrotal skin to suggest a breech of skin and a percutaneous infection.

Staphylococcus aureus and Escherichia coli have been reported to cause localised suppurative disease of the u r i na ry tract i nc lud ing prostat i t is , orchi t is and epididymitis in the newborn period. 1Hendricks and KeUet have reported a case of testicular abscess due to E coli. 5 This neonate had developed septicemia on the third day of life due to E coli. On the 14th day of life, a firm, tender mass measuring 2 cm in diameter was found in the right scrotum. At operation, the right sc ro tum was exp lored and found to conta in an enlarged inflamed testicle, which on incision contained

a green purulent material that yielded E coli on culture. McLactney and Steward have described a case of

suppurative orchitis due to Pseudomonas aeruginosa in a 10-day-old neonate? The neonate had presented with vormiting and a tense tender swelling in the right groin. On surgical exploration, a swollen testicle was found in the right inguinal canal. Histology of the testicle revealed an abscess within the tunica albuginea with growth of Pseudomonas aeruginosa on culture. Foster and co-workers described testicular abscess due to Salmonella enteritidis in a 1-month-old newborn. 7 Surgical debridement and drainage, combined with ant ibiot ic therapy , were cura t ive and sa lvaged testicular tissue.

In our case, there were no systemic features of �9 infection at the time of presentation. The diagnosis was m a d e by u l t r a sound , thus avo id ing a surgical exploration. To the best of our knowledge, this is the first report of an anaerobic testicular abscess with polymicrobial infection in a neonate.

REFERENCES

1. Klein JO. Bacterial Infections of the Urinary Tract. In Remington J, Klein JO eds. Infectious Diseases of the Fetus and Newborn infant, 3rd edn. Philadelphia, WB Saunders Company, 1990; 692-697.

2. Welson-Storey D. Scrotal swellings in the under 5s. Arch Dis Child 1987; 62 : 50-52.

3. Caldamore AA, Valvo JR, Atebaemakein VK, Rabinowitz R. Acute scrotal swellings in children. J Paed Surg 1984; 19 : 581-584.

4. Aenon SS. Anaerobic Infections. In Behrman RE, Kliegman RM, Kevin A, eds. Nelson Textbook of Pediatrics, 15th edn. Bangalore, Prism India Limited, 1995; 817-821.

5. Hendricks WM, KeUet GN. Scrotal mass in a neonate : Testicular abscess. Am J Dis Child 1975; 129 1361-1362.

6. McCartney ET, Stewart I. Suppurative orchitis due to Pseudomonas. J Paed 1958; 52 : 451--453.

7. Foster R, Weber TR, Kleiman M, Grosfeld JL. Salmonella enteritidis : testicular abscess in a newborn. J Urol 1983 Oct, 130 : 790-791.

562 Indian Journal of Pediatrics, Volume 68--June, 2001