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Scrotal Imaging in the Henoch-Schönlein Syndrome
0022-5347/80/1244-0568$02.00/0 Vol. 124, October
THE JOURNAL OF UROLOGY
Printed mU.S.A.
Copyright© 1980 by The Williams & Wilkins Co.
SCROTAL IMAGING IN THE HENOCH-SCHONLEIN SYNDROME BARRY S. STEIN, A. RICHARD KENDALL, H. THEODORE HARKE, J. LAWRENCE NAIMAN LESTER KARAFIN
AND
From the Department of Urology, St. Christopher's Hospital for Children and Temple University School of Medicine, Philadelphia, Pennsylvania
ABSTRACT
Testicular involvement in patients with Henoch-Schonlein syndrome may occur in as high as 15 per cent of the cases. Scrotal imaging is extremely accurate in differentiating hyperemia (vasculitis) from impairment of blood flow encountered in torsion of the spermatic cord, the most common cause of acute scrotal swelling in children. The differentiation between torsion of the spermatic cord hours. Followup examination 4 weeks later showed that the and other causes of acute scrotal pain and swelling is a constant testis had remained normal in size and consistency without any challenge. In the pediatric patient the diagnosis must still be pain during palpation. torsion until proved otherwise, although this condition is unDISCUSSION usual in a 4-year-old child. Recent reports have focused on the association of scrotal pain and swelling with Henoch-Schonlein The success of radionuclide imaging of the scrotum in the syndrome. 1- 3 The Henoch-Schonlein syndrome, a generalized diagnosis of suspected torsion of the spermatic cord is well vasculitis, presents clinically as a maculopapular skin rash with documented.5-7 99mTechnetium sodium pertechnetate, with an frequent involvement of the gastrointestinal tract, joints and estimated radiation dosage to the testes of 0.32 rad, has been kidneys, and accompanying hematuria. Acute scrotal swelling used in our institutions and previous reports have demonstrated has been recognized recently as a manifestation of this syn- this type of investigation to be as accurate as the Doppler drome in as high as 15 per cent of the cases. 3 Most of the early ultrasound stethoscope. 5 With torsion of the spermatic cord cases were diagnosed to have torsion of the spermatic cord and either complete or partial occlusion of the spermatic artery underwent, in retrospect, unnecessary operative exploration. prevents blood and radionuclide from adequately perfusing the The question, thus, arises of whether it is justifiable to adopt a testis. Thus, scrotal imaging demonstrates a decrease in radionon-operative approach and assume that scrotal swelling is nuclide activity (fig. 2). These scrotal scans are typical of attributable to the vasculitis. Since the presumed mechanism torsion, which was documented by operative exploration. They for scrotal swelling in this syndrome is on the basis of a vasculitis can be compared to a perfectly normal scan, showing both the scrotal scan with its ability to assess perfusion should be testes of equal size and similar radionuclide distribution (fig. 3). effective in differentiating impairment of blood flow as seen in Thus, scrotal imaging with technetium provides a means to a torsion from patients with vasculitis. assess testicular blood flow. Local hyperemia from any cause A documented case of torsion in a young boy with Henoch- will give a similar appearance and, thus, the inability to differSchonlein syndrome reveals the dangers inherent to this type entiate between a vasculitis or infection. The true value of the of generalization. 4 scrotal imaging, therefore, lies in the differentiation of torsion from inflammatory conditions. CASE REPORT While scrotal swelling owing to vasculitis is described freB. 0., a 4-year-old black boy, had fever and painful swelling quently simultaneous torsion of the spermatic cord certainly is of both feet approximately 1 week after having been bitten by insects. The swelling progressed with the development of a rash over the arms and legs, and the child was hospitalized. On admission a pink maculopapular rash was apparent on his wrists, elbows and legs, with many of these lesions having petechial centers. Scrotal examination was normal and there were no genitourinary complaints elicited. Admission laboratory data, including urinalysis and all hematologic testing, were within normal limits. The presumptive diagnosis was HenochSchonlein syndrome. Approximately 12 hours after the child was hospitalized he had pain in the left hemiscrotum and reexamination revealed left testicular enlargement with erythema and edema of the overlying scrotal skin, including purpuric lesions. While the testicle was firm, enlarged, tender and in a vertical lie, the epididymis was not distinctly palpable. Since the diagnosis of torsion of the spermatic cord could not be excluded scrotal imaging was performed (fig. 1). This noninvasive study revealed increased radionuclide uptake by the left testicle, thus ruling out the possibility of torsion. The child was treated conservatively with 2 mg./kg. prednisone daily and most of the scrotal pain and swelling had disappeared within 24
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l R I
I
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Accepted for publication December 7, 1979. Read at annual meeting of American Urological Association, New York, New York, May 13-17, 1979.
... II \\
\
\
'.
Fm. 1. Although there is bilateral distribution of radionuclide there is increased uptake on left side.
568
SCROTAL IMAGING IN HENOCH-SCHONLEIN SYNDROME
569
B
•
R
Fm. 2. A, area of decreased radionuclide in right testicle confirmed as torsion. B, evidence of decreased uptake of radionuclide in left testicle. Dense rim around necrotic testicle represents periorchitis involvement.
possible and differentiation on clinical examination may not be possible. Children with Henoch-Schonlein syndrome who have suspected testicular involvement may, therefore, benefit from 9~echnetium imaging of the scrotum. In fact, it probably is advisable to image any scrotal swelling in a child if the decision is made not to operate. REFERENCES 1. Eadie, D. G. A. and Higgins, P. M.: Apparent torsion of the testicle
2. 3. 4. 5.
6. Fm. 3. Normal nuclear scan demonstrates radionuclide uptake bilaterally.
7.
in a case of Henoch-Schonlein purpura. Brit. J. Surg., 51: 634, 1964. Fitzsimmons, J. S.: Uncommon complication of anaphylactoid purpura. Brit. Med. J., 4: 431, 1968. Khan, A. U., Williams, T. H. and Malek, R. S.: Acute scrotal swelling in Henoch-Schonlein syndrome. Urology, 10: 139, 1977. Loh, H. S. and Jalan, 0. M.: Testicular torsion in Henoch-Schonlein syndrome. Brit. Med. J., 2: 96, 1974. Perri, A. J., Rose, J., Feldman, A. E., Parker, J., Karafin, L. and Kendall, A. R.: An evaluation of the role of the Doppler stethoscope and the testicular scan in the diagnosis of torsion of the spermatic cord. Invest. Urol., 15: 275, 1978. Mishkin, F. S.: Differential diagnostic features of the radionuclide scrotal image. Amer. J. Roentgen., 128: 127, 1977. Lutzker, L. G., Novich, I., Perez, L. A. and Freeman, L. M.: Radionuclide scrotal imaging. Appl. Rad. Nucl. Med., 6: 187, 1977.
THE JOURNAL OF UROLOGY
Printed mU.S.A.
Copyright© 1980 by The Williams & Wilkins Co.
SCROTAL IMAGING IN THE HENOCH-SCHONLEIN SYNDROME BARRY S. STEIN, A. RICHARD KENDALL, H. THEODORE HARKE, J. LAWRENCE NAIMAN LESTER KARAFIN
AND
From the Department of Urology, St. Christopher's Hospital for Children and Temple University School of Medicine, Philadelphia, Pennsylvania
ABSTRACT
Testicular involvement in patients with Henoch-Schonlein syndrome may occur in as high as 15 per cent of the cases. Scrotal imaging is extremely accurate in differentiating hyperemia (vasculitis) from impairment of blood flow encountered in torsion of the spermatic cord, the most common cause of acute scrotal swelling in children. The differentiation between torsion of the spermatic cord hours. Followup examination 4 weeks later showed that the and other causes of acute scrotal pain and swelling is a constant testis had remained normal in size and consistency without any challenge. In the pediatric patient the diagnosis must still be pain during palpation. torsion until proved otherwise, although this condition is unDISCUSSION usual in a 4-year-old child. Recent reports have focused on the association of scrotal pain and swelling with Henoch-Schonlein The success of radionuclide imaging of the scrotum in the syndrome. 1- 3 The Henoch-Schonlein syndrome, a generalized diagnosis of suspected torsion of the spermatic cord is well vasculitis, presents clinically as a maculopapular skin rash with documented.5-7 99mTechnetium sodium pertechnetate, with an frequent involvement of the gastrointestinal tract, joints and estimated radiation dosage to the testes of 0.32 rad, has been kidneys, and accompanying hematuria. Acute scrotal swelling used in our institutions and previous reports have demonstrated has been recognized recently as a manifestation of this syn- this type of investigation to be as accurate as the Doppler drome in as high as 15 per cent of the cases. 3 Most of the early ultrasound stethoscope. 5 With torsion of the spermatic cord cases were diagnosed to have torsion of the spermatic cord and either complete or partial occlusion of the spermatic artery underwent, in retrospect, unnecessary operative exploration. prevents blood and radionuclide from adequately perfusing the The question, thus, arises of whether it is justifiable to adopt a testis. Thus, scrotal imaging demonstrates a decrease in radionon-operative approach and assume that scrotal swelling is nuclide activity (fig. 2). These scrotal scans are typical of attributable to the vasculitis. Since the presumed mechanism torsion, which was documented by operative exploration. They for scrotal swelling in this syndrome is on the basis of a vasculitis can be compared to a perfectly normal scan, showing both the scrotal scan with its ability to assess perfusion should be testes of equal size and similar radionuclide distribution (fig. 3). effective in differentiating impairment of blood flow as seen in Thus, scrotal imaging with technetium provides a means to a torsion from patients with vasculitis. assess testicular blood flow. Local hyperemia from any cause A documented case of torsion in a young boy with Henoch- will give a similar appearance and, thus, the inability to differSchonlein syndrome reveals the dangers inherent to this type entiate between a vasculitis or infection. The true value of the of generalization. 4 scrotal imaging, therefore, lies in the differentiation of torsion from inflammatory conditions. CASE REPORT While scrotal swelling owing to vasculitis is described freB. 0., a 4-year-old black boy, had fever and painful swelling quently simultaneous torsion of the spermatic cord certainly is of both feet approximately 1 week after having been bitten by insects. The swelling progressed with the development of a rash over the arms and legs, and the child was hospitalized. On admission a pink maculopapular rash was apparent on his wrists, elbows and legs, with many of these lesions having petechial centers. Scrotal examination was normal and there were no genitourinary complaints elicited. Admission laboratory data, including urinalysis and all hematologic testing, were within normal limits. The presumptive diagnosis was HenochSchonlein syndrome. Approximately 12 hours after the child was hospitalized he had pain in the left hemiscrotum and reexamination revealed left testicular enlargement with erythema and edema of the overlying scrotal skin, including purpuric lesions. While the testicle was firm, enlarged, tender and in a vertical lie, the epididymis was not distinctly palpable. Since the diagnosis of torsion of the spermatic cord could not be excluded scrotal imaging was performed (fig. 1). This noninvasive study revealed increased radionuclide uptake by the left testicle, thus ruling out the possibility of torsion. The child was treated conservatively with 2 mg./kg. prednisone daily and most of the scrotal pain and swelling had disappeared within 24
•
I
l R I
I
I
Accepted for publication December 7, 1979. Read at annual meeting of American Urological Association, New York, New York, May 13-17, 1979.
... II \\
\
\
'.
Fm. 1. Although there is bilateral distribution of radionuclide there is increased uptake on left side.
568
SCROTAL IMAGING IN HENOCH-SCHONLEIN SYNDROME
569
B
•
R
Fm. 2. A, area of decreased radionuclide in right testicle confirmed as torsion. B, evidence of decreased uptake of radionuclide in left testicle. Dense rim around necrotic testicle represents periorchitis involvement.
possible and differentiation on clinical examination may not be possible. Children with Henoch-Schonlein syndrome who have suspected testicular involvement may, therefore, benefit from 9~echnetium imaging of the scrotum. In fact, it probably is advisable to image any scrotal swelling in a child if the decision is made not to operate. REFERENCES 1. Eadie, D. G. A. and Higgins, P. M.: Apparent torsion of the testicle
2. 3. 4. 5.
6. Fm. 3. Normal nuclear scan demonstrates radionuclide uptake bilaterally.
7.
in a case of Henoch-Schonlein purpura. Brit. J. Surg., 51: 634, 1964. Fitzsimmons, J. S.: Uncommon complication of anaphylactoid purpura. Brit. Med. J., 4: 431, 1968. Khan, A. U., Williams, T. H. and Malek, R. S.: Acute scrotal swelling in Henoch-Schonlein syndrome. Urology, 10: 139, 1977. Loh, H. S. and Jalan, 0. M.: Testicular torsion in Henoch-Schonlein syndrome. Brit. Med. J., 2: 96, 1974. Perri, A. J., Rose, J., Feldman, A. E., Parker, J., Karafin, L. and Kendall, A. R.: An evaluation of the role of the Doppler stethoscope and the testicular scan in the diagnosis of torsion of the spermatic cord. Invest. Urol., 15: 275, 1978. Mishkin, F. S.: Differential diagnostic features of the radionuclide scrotal image. Amer. J. Roentgen., 128: 127, 1977. Lutzker, L. G., Novich, I., Perez, L. A. and Freeman, L. M.: Radionuclide scrotal imaging. Appl. Rad. Nucl. Med., 6: 187, 1977.