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Testicular scanning as a diagnostic aid in evaluatingscrotal pain
76 0
Rettc %
Brief clinical and laboratory observations
The Journal of Pediatrics Mar 1979
DISCUSSION
Hb
Gm/dL
30
[ prednisolone 2mg/kg/day] l
I
tOOmt
I
lOOm[
G5rn o--"
_o
25 2.0 1.5 1.0 ,o- -~
0.5 / e~.
~ o -
I
-
-
o -
2
_
- o -
3
-
- - o -
4
-
-
o"
5
G
TREATMENT
7
IN
8
9
10
WEEKS
Figure. Clinical course of the patient after treatment: 9 9 = Hemoglobin concentrations; o .... o = reticulocytes: ~,blood transfusions; tthe patient's death. The indirect antiglobulin test was also positive (1:16). A significant cold agglutinin was not detected. The serum lactic dehydrogenase was 7,760 units (normal range: 100 to 200 units). The erythrocyte enzymes did not differ from the pattern of normal children of the same age. The serum transaminase values were normal. Serum concentrations of immunoglobulins were elevated for age: IgM 1,180 mg/dl, lgA 48 mg/dl, and lgM 309 mg/dl. Rubella virus was not isolated from the infant's throat, urine, or bone marrow. Rubella antibody titers revealed titers of 1: 1024 in the baby's serum and 1:512 in her mother's serum. The patient's serum contained IgM-specific antibody with a titer of 1:8. The complement fixation test for cytomegalovirus was negative. The patient had 46XX normal female karyotype. The clinical course after admission is depicted in the Figure. The infant received steroid therapy after transfusions, but in vain. The positive antiglobulin test did not change. The patient died at 9 months of age in congestive heart failure secondary to severe anemia, despite a course of prednisolone for five weeks. Autopsy was not obtained.
A number of infants with congenital rubella accompanied by thrombocytopenic purpura or hemolytic anemia have been reported. Most of the reported patients with hemolytic anemia have had definite evidence of erythroid hyperplasia and a negative Coombs test. The patient discussed in this article presented with 2 positive Coombs test and hypoplasia of all the elements of the bone marrow, including megakaryocytes, erythrocytes, and granulocytes. Only two instances of generalized bone marrow depression in congenital rubella have been reported; one survived after a good response to steroid therapy,' and the other died at 6 months of a g e / S a t o et aF' reported one of three patients (4 to 8 years of age) with hemolytic anemia and rubella infection had a positive Coombs test by both direct and indirect methods. A u t o i m m u n e hemolytic anemia in early infancy is rare and has not previously been reported in congenital rubella. We thank Dr. S. Miwa, of Department of Internal Medicine, Yamaguchi University and Dr. T. Matsuhashi, of Tokyo University for helpful discussion and criticism. REFERENCES 1. Lafer CZ, and Morrison AN: Thrombocytopenic purpura progressing to transient hypoplastic anemia in a new born with rubella syndrome, Pediatrics 38:499, 1966. 2. Horstmann DM, Banatvala JE, Riordan JT, Payne MC, Whittemore R, Opton EM, and Florey C: Maternal rubella and the rubella syndrome in infants, Am J Dis Child 110:408, 1965. 3. Sato M, Takeuchi M, Kimura Y, Kuribayashi T, Shitara T, and Kuroume Y: Three cases of acute hemolytic anemia in rubella infection, Acta Paediatr Jap 81:387, 1977.
Testicular scanning as a diagnostic aid in evaluating scrotal pain Robert A. Boedecker, M.D.,* John R. Sty, M.D., and Juda Z. Jona, M.D., Milwaukee, Wis.
W H E N AN INFANT or child presents with a swollen, tender testicle, the clinical differentiation of testicular torsion from inflammatory lesions is of primary importance. Owing to the morbidity of delaying surgery for
From the Departments of Radiology and Surgery at Milwaukee Children's Hospital. *Reprint address: Fellow. Pediatric Radlologv, Milwaukee Children's Hospital, 1700 W. Wisconsin Ave.. P.O. Box 1997, Milwaukee. WI 53201.
testicular torsion, surgical exploration has been the accepted practice when diagnosis was unclear. Nuclear imaging techniques we.re introduced in 1973 as an additional method to evaluate this group o f patients.'.'-' Nuclear imaging serves as a complementary procedure in the diagnostic evaluation o f the swollen testicle. MATERIALS
AND
METHODS
Thirty-two boys, ages one to 16 years, complaining of sudden onset of scrotal pain and swelling, were seen and
0022-3476/79/500760+03500.30/0 9 1979 The C. V. Mosby Co.
Volume 94 Number 5
Brie/" clinical and laboratory observations
76 1
R
R
Fig. 1. A, Perfusion phase. Normal, symmetrical perfusion (arrow). B, Delayed image. Increased tissue activity (arrow) due to the hyperemia of inflammation.
R
R
| Fig. 2. A, Perfusion phase. Decreased perfusion (arrow). B, Delayed image. Decreased tissue activity (arrow) due to torsion of the testis.
evaluated initially by their personal physician or his consultants. All had the onset of symptoms for less than 12 hours; a single exception was a patient whose symptoms were of one month's duration. A history was taken and physical examination was given. Specific inquiry was made regarding possible testicular trauma. Despite a physical examination, urinalysis, and hemogram, a specific diagnosis was not always
possible. To complete the evaluation, testicular nuclear imaging was obtained. IMAGING
TECHNIQUE
The patient is positioned on the examination table in a supine position with his thighs and ankles apposed. The penis is taped onto the anterior abdominal wall and a specially designed ~ i n c h lead frame shield is placed
76 2
Brief cfinical and laboratory observations
between the scrotum and the thighs. The radioisotope, ......TcO~ (technetium-99m pertechnetate) calculated at 6 mCi/m ~of body surface area is injected as a bolus into the antecubital vein. The gonadal dose is estimated at less than 75 millirads? .~ A gamma camera is used to record the testicular perfusion at four-second intervals for the first minute. The tissue pooling phase is then recorded at 1, 5, 10, and 15 minutes. RESULTS All studies were technically satisfactory. The unaffected testicle served as a control for comparison. The perfusion scan results were used to divide the patients into two groups: normal perfusion and reduced perfusion. Normal perfusion. In 26 of the boys, the testicular circulation appeared unimpaired and torsion could be ruled out. In 25 of these, increased tissue pooling (a "hot" scan) suggested hyperemia due to an inflammatory process (Fig. 1). Epididymo-orchitis was then the clinical" diagnosis and the children were either hospitalized for a short period of observation or sent home for outpatient follow-up. Of these 25 boys, 23 recovered with medical therapy; the involved testicle appeared to be normal on follow-up physical examinations. In two instances, however, a 2'~year-old child and an 8-year-old child, surgical drainage of an epididymal abscess became necessary. One child with normal perfusion of the testicle and normal tissue pooling (both testicles appearing equal in their scanning characteristics) was surgically explored because of the persisting clinical findings. Torsion of the appendix testis was found, with the testicle itself entirely normal. Reduced perfusion. In six boys, decreased testicular perfusion was seen on the circulatory phase of the scan. In two, quantitation suggested only a moderate reduction of blood flow. The tissue pooling phase was reduced ("cold") in all six (Fig. 2). Torsion of the testicular vascular pedicle was confirmed at the time of emergent operation in these six patients. The two with partial perfusion defects were found to have early torsion, i.e., testicular venous congestion was marked but incision of the tunica of the testis demonstrated normal arterial bleeding. DISCUSSION The clinical differentiation between acute testicular inflammation and torsion is frequently made on the basis of history and careful examination. In infants and small children, however, this discrimination is more difficult, but equally important. Preservation of the hormonal and spermatogenic functions of the testis is possible only within six to ten hours after the onset of vascular compromise? thus necessitating prompt and accurate
The Journal Of Pediatrics May 1979
diagnosis. In the past, an equivocal diagnosis requ!red surgical exploration for diagnostic and, if necessary, therapeutic purposes. Using the technique first described by Nadel et al' in 1973, accurate assessment of testicular perfusion is possible. Pediatric applications were reported by Hitch et al, '~ who modified the original technique, and prompted our evaluation and application of this method. Since all of our patients were examined by their personal physician initially, only those with an equivocal clinical presentation were referred for testicular scanning. The appearance of normal or increased perfusion and exaggerated tissue uptake ("hot" scan) denoted inflammation and its associated hyperemia. Partial deviation from this rule was seen in a boy with torsion of the appendix testis, in whom a normal scan was found. Since neither decreased perfusion nor inflammation of the testicle are present in such a situation, one must accept that radioscanning in this instance assures the surgeon that testicular perfusion is not compromised. In contradistinction, when the perfusion was diminished and the testicle appeared "cold" on the scan, torsion was confirmed at surgery in each instance. In fact, quantitation of the perfusion by comparing one testis to the other enabled us to determine two instances of early torsion in which there was venous congestion due to obstruction, but the arterial inflow was still present. The technique we have described has proved to be a most valuable diagnostic aid, when the clinical diagnosis is equivocal. The rapidity, simplicity, and safety of this test, as well as its noninvasive nature, often allow a specific diagnosis to be made in patients with acute testicular pain. Prompt surgery for ischemia need not and should not be delayed by the examination. Although false negative scans have been reported, they can be minimized by considering the history and clinical examination at the time of scan interpretation. REFERENCES 1. Nadel NS, Critter MH, Hahn LC, et al: Preoperative diagnosis of testicular torsion, Urology 1:478, 1973. 2. Daffa VS, and Tanaka T: Diagnosis of testicular torsion by radionuclide imaging, J PEDIATR91:167, 1977. 3. James AE, Wagner HN, and Cooke RE, editors: Pediatric nuclear medicine, Philadelphia, 1974, WB Saunders Company, p 232. 4. Naiman JL, Harcke T, Sebastianelli J, and Stein BS: Scrotal imaging in the Henoch-Schbnlein syndrome, J PEDIATR 92:1021, 1978. 5. Smith GI: Cellular changes from graded testicular ischemia, J Urol 73:355, 1955. 6. Hitch DC, Gilday DL, Shandling B, and Savage JP: A new approach to the diagnosis of testicular torsion, J Pediatr Surg 11:537, 1976.
Rettc %
Brief clinical and laboratory observations
The Journal of Pediatrics Mar 1979
DISCUSSION
Hb
Gm/dL
30
[ prednisolone 2mg/kg/day] l
I
tOOmt
I
lOOm[
G5rn o--"
_o
25 2.0 1.5 1.0 ,o- -~
0.5 / e~.
~ o -
I
-
-
o -
2
_
- o -
3
-
- - o -
4
-
-
o"
5
G
TREATMENT
7
IN
8
9
10
WEEKS
Figure. Clinical course of the patient after treatment: 9 9 = Hemoglobin concentrations; o .... o = reticulocytes: ~,blood transfusions; tthe patient's death. The indirect antiglobulin test was also positive (1:16). A significant cold agglutinin was not detected. The serum lactic dehydrogenase was 7,760 units (normal range: 100 to 200 units). The erythrocyte enzymes did not differ from the pattern of normal children of the same age. The serum transaminase values were normal. Serum concentrations of immunoglobulins were elevated for age: IgM 1,180 mg/dl, lgA 48 mg/dl, and lgM 309 mg/dl. Rubella virus was not isolated from the infant's throat, urine, or bone marrow. Rubella antibody titers revealed titers of 1: 1024 in the baby's serum and 1:512 in her mother's serum. The patient's serum contained IgM-specific antibody with a titer of 1:8. The complement fixation test for cytomegalovirus was negative. The patient had 46XX normal female karyotype. The clinical course after admission is depicted in the Figure. The infant received steroid therapy after transfusions, but in vain. The positive antiglobulin test did not change. The patient died at 9 months of age in congestive heart failure secondary to severe anemia, despite a course of prednisolone for five weeks. Autopsy was not obtained.
A number of infants with congenital rubella accompanied by thrombocytopenic purpura or hemolytic anemia have been reported. Most of the reported patients with hemolytic anemia have had definite evidence of erythroid hyperplasia and a negative Coombs test. The patient discussed in this article presented with 2 positive Coombs test and hypoplasia of all the elements of the bone marrow, including megakaryocytes, erythrocytes, and granulocytes. Only two instances of generalized bone marrow depression in congenital rubella have been reported; one survived after a good response to steroid therapy,' and the other died at 6 months of a g e / S a t o et aF' reported one of three patients (4 to 8 years of age) with hemolytic anemia and rubella infection had a positive Coombs test by both direct and indirect methods. A u t o i m m u n e hemolytic anemia in early infancy is rare and has not previously been reported in congenital rubella. We thank Dr. S. Miwa, of Department of Internal Medicine, Yamaguchi University and Dr. T. Matsuhashi, of Tokyo University for helpful discussion and criticism. REFERENCES 1. Lafer CZ, and Morrison AN: Thrombocytopenic purpura progressing to transient hypoplastic anemia in a new born with rubella syndrome, Pediatrics 38:499, 1966. 2. Horstmann DM, Banatvala JE, Riordan JT, Payne MC, Whittemore R, Opton EM, and Florey C: Maternal rubella and the rubella syndrome in infants, Am J Dis Child 110:408, 1965. 3. Sato M, Takeuchi M, Kimura Y, Kuribayashi T, Shitara T, and Kuroume Y: Three cases of acute hemolytic anemia in rubella infection, Acta Paediatr Jap 81:387, 1977.
Testicular scanning as a diagnostic aid in evaluating scrotal pain Robert A. Boedecker, M.D.,* John R. Sty, M.D., and Juda Z. Jona, M.D., Milwaukee, Wis.
W H E N AN INFANT or child presents with a swollen, tender testicle, the clinical differentiation of testicular torsion from inflammatory lesions is of primary importance. Owing to the morbidity of delaying surgery for
From the Departments of Radiology and Surgery at Milwaukee Children's Hospital. *Reprint address: Fellow. Pediatric Radlologv, Milwaukee Children's Hospital, 1700 W. Wisconsin Ave.. P.O. Box 1997, Milwaukee. WI 53201.
testicular torsion, surgical exploration has been the accepted practice when diagnosis was unclear. Nuclear imaging techniques we.re introduced in 1973 as an additional method to evaluate this group o f patients.'.'-' Nuclear imaging serves as a complementary procedure in the diagnostic evaluation o f the swollen testicle. MATERIALS
AND
METHODS
Thirty-two boys, ages one to 16 years, complaining of sudden onset of scrotal pain and swelling, were seen and
0022-3476/79/500760+03500.30/0 9 1979 The C. V. Mosby Co.
Volume 94 Number 5
Brie/" clinical and laboratory observations
76 1
R
R
Fig. 1. A, Perfusion phase. Normal, symmetrical perfusion (arrow). B, Delayed image. Increased tissue activity (arrow) due to the hyperemia of inflammation.
R
R
| Fig. 2. A, Perfusion phase. Decreased perfusion (arrow). B, Delayed image. Decreased tissue activity (arrow) due to torsion of the testis.
evaluated initially by their personal physician or his consultants. All had the onset of symptoms for less than 12 hours; a single exception was a patient whose symptoms were of one month's duration. A history was taken and physical examination was given. Specific inquiry was made regarding possible testicular trauma. Despite a physical examination, urinalysis, and hemogram, a specific diagnosis was not always
possible. To complete the evaluation, testicular nuclear imaging was obtained. IMAGING
TECHNIQUE
The patient is positioned on the examination table in a supine position with his thighs and ankles apposed. The penis is taped onto the anterior abdominal wall and a specially designed ~ i n c h lead frame shield is placed
76 2
Brief cfinical and laboratory observations
between the scrotum and the thighs. The radioisotope, ......TcO~ (technetium-99m pertechnetate) calculated at 6 mCi/m ~of body surface area is injected as a bolus into the antecubital vein. The gonadal dose is estimated at less than 75 millirads? .~ A gamma camera is used to record the testicular perfusion at four-second intervals for the first minute. The tissue pooling phase is then recorded at 1, 5, 10, and 15 minutes. RESULTS All studies were technically satisfactory. The unaffected testicle served as a control for comparison. The perfusion scan results were used to divide the patients into two groups: normal perfusion and reduced perfusion. Normal perfusion. In 26 of the boys, the testicular circulation appeared unimpaired and torsion could be ruled out. In 25 of these, increased tissue pooling (a "hot" scan) suggested hyperemia due to an inflammatory process (Fig. 1). Epididymo-orchitis was then the clinical" diagnosis and the children were either hospitalized for a short period of observation or sent home for outpatient follow-up. Of these 25 boys, 23 recovered with medical therapy; the involved testicle appeared to be normal on follow-up physical examinations. In two instances, however, a 2'~year-old child and an 8-year-old child, surgical drainage of an epididymal abscess became necessary. One child with normal perfusion of the testicle and normal tissue pooling (both testicles appearing equal in their scanning characteristics) was surgically explored because of the persisting clinical findings. Torsion of the appendix testis was found, with the testicle itself entirely normal. Reduced perfusion. In six boys, decreased testicular perfusion was seen on the circulatory phase of the scan. In two, quantitation suggested only a moderate reduction of blood flow. The tissue pooling phase was reduced ("cold") in all six (Fig. 2). Torsion of the testicular vascular pedicle was confirmed at the time of emergent operation in these six patients. The two with partial perfusion defects were found to have early torsion, i.e., testicular venous congestion was marked but incision of the tunica of the testis demonstrated normal arterial bleeding. DISCUSSION The clinical differentiation between acute testicular inflammation and torsion is frequently made on the basis of history and careful examination. In infants and small children, however, this discrimination is more difficult, but equally important. Preservation of the hormonal and spermatogenic functions of the testis is possible only within six to ten hours after the onset of vascular compromise? thus necessitating prompt and accurate
The Journal Of Pediatrics May 1979
diagnosis. In the past, an equivocal diagnosis requ!red surgical exploration for diagnostic and, if necessary, therapeutic purposes. Using the technique first described by Nadel et al' in 1973, accurate assessment of testicular perfusion is possible. Pediatric applications were reported by Hitch et al, '~ who modified the original technique, and prompted our evaluation and application of this method. Since all of our patients were examined by their personal physician initially, only those with an equivocal clinical presentation were referred for testicular scanning. The appearance of normal or increased perfusion and exaggerated tissue uptake ("hot" scan) denoted inflammation and its associated hyperemia. Partial deviation from this rule was seen in a boy with torsion of the appendix testis, in whom a normal scan was found. Since neither decreased perfusion nor inflammation of the testicle are present in such a situation, one must accept that radioscanning in this instance assures the surgeon that testicular perfusion is not compromised. In contradistinction, when the perfusion was diminished and the testicle appeared "cold" on the scan, torsion was confirmed at surgery in each instance. In fact, quantitation of the perfusion by comparing one testis to the other enabled us to determine two instances of early torsion in which there was venous congestion due to obstruction, but the arterial inflow was still present. The technique we have described has proved to be a most valuable diagnostic aid, when the clinical diagnosis is equivocal. The rapidity, simplicity, and safety of this test, as well as its noninvasive nature, often allow a specific diagnosis to be made in patients with acute testicular pain. Prompt surgery for ischemia need not and should not be delayed by the examination. Although false negative scans have been reported, they can be minimized by considering the history and clinical examination at the time of scan interpretation. REFERENCES 1. Nadel NS, Critter MH, Hahn LC, et al: Preoperative diagnosis of testicular torsion, Urology 1:478, 1973. 2. Daffa VS, and Tanaka T: Diagnosis of testicular torsion by radionuclide imaging, J PEDIATR91:167, 1977. 3. James AE, Wagner HN, and Cooke RE, editors: Pediatric nuclear medicine, Philadelphia, 1974, WB Saunders Company, p 232. 4. Naiman JL, Harcke T, Sebastianelli J, and Stein BS: Scrotal imaging in the Henoch-Schbnlein syndrome, J PEDIATR 92:1021, 1978. 5. Smith GI: Cellular changes from graded testicular ischemia, J Urol 73:355, 1955. 6. Hitch DC, Gilday DL, Shandling B, and Savage JP: A new approach to the diagnosis of testicular torsion, J Pediatr Surg 11:537, 1976.