A ten-day-old neonate boy presented to the hospital with the complaint of viral gastroenteritis. All the laboratory investigations and physical examinations were normal. During his physical evaluation, the doctors discovered a swelling in the left scrotum for which they made a diagnosis of a left hydrocele. They discharged the baby boy soon after and the neonate was stable with no complications.
Presentation and Examination
Seventeen days after his initial presentation, he presented to the hospital again with left scrotal swelling, erythema, fever and pus from the left scrotum. Doctors performed a physical examination to find out the cause of the signs and symptoms. The abdominal examination was unremarkable. However, a scrotal examination showed a left scrotal abscess with a rock-solid swollen testis in the left scrotum. There was no sign of herniation. Based on these findings, the doctors made a provisional diagnosis of missed neonatal testicular torsion, and they prepared him for urgent surgical exploration. Due to the signs of infection, the doctors administered intravenous antibiotics (amoxicillin with clavulanic acid and flucloxacillin) and fluids to the neonate.
During the surgical exploration, the surgeons made a midline raphe scrotal incision. They washed the pus that was coming out of the swelling. Then, they excised the necrotic scrotal wall swelling completely. Thereafter, they sent the excised tissue for histology and microbiology, for the definitive diagnosis and isolation of any micro-organism. The doctors found that there was oedema in the testis and that the tunica vaginalis was thickened. However, the doctors could not visualize any testicular torsion. They washed the wound with an antiseptic solution. Then, they stitched the skin and muscles with absorbable sutures. The surgery was a success with no complications. The neonate’s fever subsided after surgery. Oedema, erythema and pain also resolved within 2 days after the surgery.
The histology reports revealed a scrotal wall necrotizing fasciitis (Fournier gangrene). The scrotal skin was also found to be ulcerated. This diagnosis was opposite to the two preliminary diagnoses of testicular torsion or hydrocele. The microbiology reports (wound culture) identified two organisms responsible for the necrotizing fasciitis, known as Enterococcus sp. (ampicillin-sensitive) and Staphylococcus aureus (methicillin-sensitive). Based on these cultures, the doctors commenced antibiotics ampicillin and methicillin for 14 days ( five days intravenously and nine days orally). On the fifth post-operative day, they discharged the baby boy from the hospital with oral antibiotics.
The doctors had a follow-up with the neonate at two weeks, two months and six months. His wound healing and physical examination were normal.
Neonatal Necrotizing Fasciitis
Neonatal necrotizing fasciitis is an extremely rare condition (with only 80 cases of necrotizing fasciitis in neonates being published in literature) which causes mortality in 50% of the diagnosed cases. Moreover, there are many cases in which neonatal necrotizing fasciitis (Fournier Gangrene) is identified in the scrotum, which was the site of origin in this case.
Fournier gangrene affects any part of the body but most commonly involves the trunk, scrotum or perineum in neonates. The risk of this gangrene increases with preterm birth, low birth weight of the baby, decreased immunity and poor hygiene. Additionally, it can also occur due to an injury in the mentioned areas, however, this is very rare. The most common sites of entry for Fournier gangrene are colorectal, urogenital, anorectal abscesses, urinary tract infections and surgical instrumentation.
Fournier gangrene, like any other necrotizing fasciitis, occurs due to a break in the skin through which organisms spread into the subcutaneous tissue causing necrosis and obliterative endarteritis which further exacerbates the condition. Since this process happens outside the tunica vaginalis, the testicular artery blood supply is not disrupted. The initial swelling that was identified in the neonate, seventeen days prior to the surgical exploration could have been subacute inflammation occurring during the disease process. It could also have been an unresolved hydrocele, as the preliminary diagnosis stated, that eventually resolved.
The signs and symptoms include fever, malaise, pain and swelling. The diagnosis of Fournier gangrene is usually clinical. However, the doctors may perform an ultrasound or CT scan to rule out testicular pathologies and to aid in diagnosis if an experienced surgeon is not available. The management includes immediate resuscitation with fluids and broad-spectrum antibiotics along with urgent surgical debridement of the necrotizing fasciitis.
Neonatal testicular torsion is the torsion of the testis within the scrotum The signs and symptoms include unilateral, often painless scrotal swelling and erythema of overlying skin. The management however varies, with some doctors managing it conservatively and others going for surgical exploration In this case report, immediate surgical exploration was done as the diagnosis was unclear. There was no need for investigations as the fever, and the unstable status of the neonate warranted immediate surgical exploration.
It is important to note that if a neonate presents with scrotal swelling, all testicular pathologies must be ruled out. If an experienced surgeon is not available, the doctors must perform an ultrasound scan to rule out common testicular pathologies such as obstructed hernia, tense hydrocele, or hydrocele of the cord.