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Table of Contents   
CASE REPORT
Year : 2023  |  Volume : 28  |  Issue : 6  |  Page : 514-516
 

Meconium periorchitis is amenable to prompt radiological diagnosis


1 Department of Pediatric Surgery, Maternity and Children's Hospital (Under Ministry of Health), Najran, Saudi Arabia
2 Department of Radiology, Maternity and Children's Hospital (Under Ministry of Health), Najran, Saudi Arabia

Date of Submission23-Jan-2023
Date of Decision24-Apr-2023
Date of Acceptance23-Jun-2023
Date of Web Publication28-Sep-2023

Correspondence Address:
Rajendran Ramaswamy
Department of Pediatric Surgery, Maternity and Children's Hospital (Under Ministry of Health), PB No. 3600, Najran
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_21_23

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   Abstract 


Scrotal swellings in neonates are very common. A 25-day-old male child had right-sided firm, nontender scrotal swelling. Ultrasound scan (USS) diagnosed as meconium periorchitis (MPO). At 70 days of age, repeat USS and plain abdominoscrotal radiograph confirmed MPO, and surgery was avoided. Radiological diagnosis and management of MPO are discussed.


Keywords: Meconium periorchitis, neonatal, scrotal calcification, scrotal swelling, scrotal ultrasound


How to cite this article:
Ramaswamy R, Abdella K, Hegab SM. Meconium periorchitis is amenable to prompt radiological diagnosis. J Indian Assoc Pediatr Surg 2023;28:514-6

How to cite this URL:
Ramaswamy R, Abdella K, Hegab SM. Meconium periorchitis is amenable to prompt radiological diagnosis. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Nov 28];28:514-6. Available from: https://www.jiaps.com/text.asp?2023/28/6/514/386438





   Introduction Top


Scrotal swellings in neonates are very common. Hydrocele, inguinoscrotal hernia, hematoma, paratesticular tumors, and testicular torsion are common possibilities. Hydroceles are present in almost 10% of all males at birth.[1] Firm scrotal swelling in the newborn is of serious pathology, which warrants elaborate diagnostic workup and even histopathological confirmation. Occasionally such swelling is amenable to radiological diagnosis and can avert unnecessary surgery. Such a case is highlighted here.


   Case Report Top


A 25-day-old male child was seen in the emergency department (ED) with right-sided scrotal swelling since birth. His gestational age was 38 W, birth weight was 3010 g, and was the product of normal vaginal delivery of G1P1 mother, in another hospital. Mother had pregnancy-induced hypertension and polyhydramnios at 7 months of pregnancy which resolved spontaneously. No fetal abnormality was discovered by an antenatal ultrasound scan (USS). He had no abdominal symptoms and tolerated normal breastfeeding. On examination, he had firm, nontender right testicular swelling.

The abdomen was not distended, soft, nontender, and without mass. Urgent inguinoscrotal USS revealed testicles showing normal size and echogenicity in the scrotum. Bilateral hydroceles with moderate to marked amounts on the right side but mild on the left side were evident. Hydroceles demonstrated multiple floating echogenic foci [Figure 1]a. No definite hernia was detected. These USS features were suggestive of bilateral meconium periorchitis (MPO). A week's course of oral antibiotics was given by the ED surgeon, with advice to attend the outpatient department (OPD). He was reviewed in pediatric surgery OPD at 70 days of age. The mother noticed a reduction in the size of the swelling. The right testicular swelling measured 3.5 cm vertical × 3 cm horizontal × 2 cm anteroposterior in size. It felt more firm than before, and its spermatic cord was thick. Ultrasonogram now detected comparative decrease of right hydrocele, and aggregation of the previously described floating echogenic foci into a rounded solid lesion measuring 3.4 cm × 2.1 cm which pushed the right testis posteriorly [Figure 1]b. Both testes were symmetrical in size, shape, and homogenous echo pattern. Abdominal sonogram excluded ascites, calcific foci, or cysts. Plain abdominal skiagram demonstrated small scattered calcifications of meconium peritonitis in the left and right hypochondria and in the lesser pelvis. Abundant spotty calcification within the right hemiscrotum was obvious [Figure 1]c. Blood hemoglobin level was 9.20 g%. Blood counts, blood urea, creatinine levels, and liver function tests were normal. Testicular tumor markers (serum alpha-fetoprotein = 76.67 ng/mL, beta-human chorionic gonadotrophin = 0.10 IU/mL, carcinoembryonic antigen = 2.43 ng/mL, and lactate dehydrogenase = 212 u/L) were within normal limits. Parenteral cefotaxime and amikacin were administered for 5 days, but no obvious reduction in swelling ensued. He was discharged for follow-up.
Figure 1: (a) Grayscale superficial transducer ultrasound of the right scrotum shows hydrocele with multiple punctate floating echogenic foci some of them associated with posterior acoustic shadowing. The testicle is of normal size and echopattern. (b) Rounded solid mass (arrows) formed by aggregation of echogenic foci. (c) Plain radiography of the abdomen shows multiple randomly distributed abnormal foci of calcifications (white arrow) with bilateral scrotal punctate calcifications more evident on the right side (black dotted arrow). EF: Echogenic foci, RT: Right testis

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   Discussion Top


Differential diagnoses of neonatal scrotal swelling are hydrocele, inguinoscrotal hernia, testicular neoplasm, testicular torsion, and organizing hematoma.[1],[2],[3],[4] Calcifying testicular neoplasms can be teratoma, Sertoli cell tumor, metastatic neuroblastoma, paratesticular rhabdomyosarcoma, and lymphoma. MPO is an extremely rare possibility. Distinguishing MPO from neoplastic swelling is crucial. Both present as a painless scrotal mass. Ultrasonography and radiography contributed immensely. Sonographic findings of MPO in the newborn period typically are scrotal hydrocele with numerous internal punctate echogenic foci, some with posterior shadowing indicative of calcifications, surrounding the otherwise normal appearing testicle, or multiple hyperechoic masses adjacent to the testicle.[1],[4],[5] Diagnostic triad of sonographic findings are scrotal mass with calcifications, hydrocele, and the absence of blood flow to the mass on Doppler studies.[4] Isolated calcifications in the scrotum may indicate neoplasms, testicular microlithiasis, or testicular torsion, followed by hemorrhagic infarction. Visualization of normal testicles on ultrasonography differentiates MPO from scrotal tumor. The presence of abdominal calcifications in addition to scrotal calcifications on radiography, reported in 38.7% of the cases, strongly suggests the possibility of MPO.[2] Symptomatic meconium peritonitis can be associated in about 20% of cases.[1] Any accompanying clinical or sonographic findings consistent with meconium ileus, peritonitis, intestinal atresia (such as fetal echogenic bowel and polyhydramnios), dilated bowel loops, ascites, or pseudocyst may aid in diagnosing MPO.[5] In the index case, a convincing diagnosis was possible by USS, plain radiography, and tumor markers. Thus, histopathologic examination (HPE) was unnecessary. MPO is typically diagnosed in the 1st week/month of life. Initially, there is a soft hydrocele or soft scrotal mass, only later presents as hard swelling.[1],[5] Rarely, during inguinal herniotomy, calcifications in the hernia sac, along with an amorphous mass adherent to the testis were discovered, which on HPE, MPO was diagnosed.[1],[2] Spillage of fetal meconium into its peritoneal cavity can occur from intrauterine bowel perforation secondary to volvulus, bowel atresia, or mesenteric vascular insufficiency. Meconium in the peritoneal cavity initiates chemical peritonitis.[3],[5] If the ruptured bowel wall heals, there may be no evidence of the cause or site of perforation, as in the index case. Peritoneal meconium can stream along patent processus vaginalis into tunica vaginalis sac in the scrotum inducing an intense inflammatory reaction resulting in a paratesticular mass. This mass hardens over subsequent weeks to months as the meconium calcifies.[3],[6]

A total of 32 cases of MPO are identified from 1986 to 2021.[2] Fetal USS (fUSS) was employed as the most frequent antenatal diagnostic imaging technique. The most common fUSS findings were fetal hydrocele with hyperechogenic lesions representing peritesticular calcifications or mass, which were found in 58.8% of cases, in which it was employed. Fetal magnetic resonance imaging (MRI), used only in 2 cases, detected scrotal mass/fluid-filled scrotum with thick wall and septa.[2] There has been no instance, in which postnatal MRI scan has been resorted to for diagnosing MPO.

Surgical intervention was pursued postnatally in 80.6% of cases of MPO, to evaluate the scrotal/inguinoscrotal mass, or due to intra-abdominal pathology (e.g. ileal atresia, bowel perforation, etc.). Of those who underwent scrotal operation, 25% underwent orchiectomy for presumed neoplasm while 65% had the scrotal mass removed.[2] Intraoperative biopsy of the mass is a better option than mass excision when MPO is considered intraoperatively. We recommend that diagnostic imaging must be adopted in peritesticular lesions before surgical intervention. Such a pathway may prevent mass excision that may damage the testicle or an unnecessary orchiectomy. Some reports of MPO with long-term follow-up without intervention found that the testes are functionally unaffected and the associated mass underwent spontaneous resolution within 1–5 years.[1],[2],[4],[5] That was why we adopted a conservative approach in our case.


   Conclusion Top


The utilization of USS and plain radiography can promptly diagnose MPO. Repeated scrotal USS could demonstrate the evolution of MPO into peritesticular mass in the index case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Durmuş G, Boybeyi-Türer Ö, Gharibzadeh-Hizal M, Ekinci S, Kiper N. Meconium periorchitis: An incidentally diagnosed rare entity during inguinal herniorraphy. Turk J Pediatr 2018;60:612-4.  Back to cited text no. 1
    
2.
Khoury MK, Twickler D, Santiago-Munoz P, Schindel D. Meconium periorchitis. J Pediatr Surg Case Rep 2021;65:101741.  Back to cited text no. 2
    
3.
Zelesco M, Abbott S. Meconium periorchitis – An uncommon cause of perinatal scrotal swelling. Sonography 2016;4:45-8.  Back to cited text no. 3
    
4.
Alanbuki AH, Bandi A, Blackford N. Meconium periorchitis: A case report and literature review. Can Urol Assoc J 2013;7:E495-8.  Back to cited text no. 4
    
5.
Kriss S, Dydynski P. Sonography of meconium periorchitis in the neonate. Am J Sonography 2019;2:1-3.  Back to cited text no. 5
    
6.
Hegde D, Utture A. Meconium periorchitis. Indian Pediatr 2015;52:449.  Back to cited text no. 6
    


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    Abstract
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