The acute scrotum in childhood

A review was made of 771 children with an acutely inflamed scrotum presenting during the 10 years 1976–1985. The relative incidence and age distribution of testicular torsion, torsion of an appendage, and epididymitis was compared. Epididymitis (13%) had a peak incidence in the first 2 years of life when urinary tract infections were common. The incidence of epididymitis was significantly lower than previously, and may reflect a changing pattern of disease. In addition, some patients with a diagnosis of epididymitis may have had infarction of a testicular appendage without haemorrhage. Torsion of a testicular appendage (58%) was most frequent at 11 years of age, 2 years before the maximum incidence of torsion of the testis (29%) at 13 years. This difference in timing may reflect a response by the cranial remnant of the müllerian duct to an increase in circulating oestrogens at the onset of puberty.     

Testicular torsion following torsion of a hydatid of Morgagni

The acute scrotum is one of the commonest surgical emergencies in pediatric practice. Early diagnosis, prompt treatment, and preventive measures are important to avoid testicular infarction. Occurrence of torsion has been previously reported following orchidopexy for undescended testis and for previous torsion of the testis. We report a case of intravaginal torsion of the testis in a patient who had previously undergone exploration and excision of a torted hydatid of Morgagni without formal orchidopexy. As exploration of the scrotum does not confer protection against subsequent torsion, orchidopexy should be routinely performed in patients who are found to have high investment of the tunica vaginalis or separation of the epididymis and testis on scrotal exploration for any reason. Correspondence to: E. J. Guiney     

Acute scrotum in Kawasaki disease: Two case reports and a literature review

Acute scrotum is a rare complication of acute Kawasaki disease (KD), less well recognized than other disease manifestations. We describe the cases of two patients, aged 59 months and 19 months, with hydrocele testis in the acute phase of KD. Scrotal ultrasound and trans‐illumination were used in the diagnosis of hydrocele testis. One patient underwent eventual surgical intervention. We reviewed the literature for a better understanding of the pathogenesis of scrotal symptoms in acute KD and investigated the clinical importance of hydrocele testis. Careful further clinical observation may elucidate the true incidence of this extracardiac symptoms, thereby clarifying the diagnostic value of this possible complication in acute KD.     

Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys

Background: Diagnosis of testicular torsion in children is challenging, as clinical presentation and findings may overlap with other diagnoses. Objective: To define the clinical and ultrasound criteria that best predict testicular torsion. Materials and methods: The records of children hospitalized for acute scrotum from 1997 to 2002 were reviewed. The clinical and ultrasound findings of children who had a final diagnosis of testicular torsion were compared with those of children who had other diagnoses (torsion of the testicular appendix, epididymitis, and epididymo-orchitis). Results: Forty-one children had testicular torsion; 131 had other diagnoses. Stepwise regression analysis yielded three factors that were significantly associated with testicular torsion: duration of pain 6 h; absent or decreased cremasteric reflex; and diffuse testicular tenderness. When the children were scored by final diagnosis for the presence of these factors (0–3), none of the children with a score of 0 had testicular torsion, whereas 87% with a score of 3 did. The ultrasound finding of decreased or absent testicular flow had a sensitivity of 63% and a specificity of 99%. Eight of ten children with testicular torsion and normal or increased testicular flow had a coiled spermatic cord on ultrasound. Conclusion: We suggest that all children with acute scrotal pain and a clinical score of 3 should undergo testicular exploration, and children with a lower probability of testicular torsion (score 1 or 2) should first undergo diagnostic ultrasound. Because the presence of testicular flow does not exclude torsion, the spermatic cord should be meticulously evaluated in all children with acute scrotum and normal or increased testicular blood flow.     

The prevalence of high insertion of scrotum,hydrocele and mobile testis in the newborn infant (36–42 weeks gestation)

The prevalence of some minor abnormalities of the male genitalia was studied in 271 boys born over a period of 2 months. The scrotal insertion on the ventral side of the penis was determined in an objective manner by measuring the ratio of the ventral and dorsal length of the unstretched penis. A scrotal insertion ratio of less than 0.48 defined high insertion of the scrotum which was found in 2.7% of our newborn infants. This anatomical finding has an important clinical significance for the performance of early circumcision. The prevalence of hydrocele in all male newborn infants was 57.9%. Extravaginal (communicating) type was present in 86% of all infants, intravaginal (noncommunicating) in 9.5%, while both types of hydrocele in the same neonate was observed in 4.5%. The relatively high frequency of mobile testes (22%) is of interest. The natural history of this entity is not fully understood and the question of follow-up remains open.     

儿童传染性非典型肺炎临床诊治体会(附6例临床病例报告)

目的　 总结分析儿童传染性非典型肺炎 (非典 )的临床表现特点。 方法 　分析 6例儿童传染性非典型肺炎流行病学史、临床症状、体征、实验室检查结果和治疗转归。 结果 　 6例患儿年龄 3个月～ 12岁 ,男女各 3例 ,均为家庭密切接触发病 ,潜伏期 2～ 12d ,发病后未再感染其密切接触者。临床主要表现为发热和咳嗽。腋温热峰 38 3～ 40 3℃ ,均持续 1周以上。多为不规则高热。伴轻度咳嗽 ,入院时外周血WBC总数多低于 5 0× 10 9/L ,以淋巴细胞分类为主 ;全部患儿胸部X片均有肺部不对称性、多叶局灶性浸润性阴影 ,多出现在发热后 3～ 5d ,多为双侧者 ,也可先为单侧 ,后发展为双侧 ,病变随病程进展而加重 ,多在病程 7d左右达高峰。全部患儿在未吸氧下血氧饱和度均在 95 %以上 ,1～ 5升 /分氧流量吸氧下达 97%～ 10 0 %。经治疗后全部临床痊愈出院 ,发热持续时间平均 8d ;胸片肺部炎症阴影明显吸收好转平均 2周。 结论 　本组儿童非典均为家庭密切接触感染 ,感染后再传染给他人的传染力低 ;临床症状体征主要表现在呼吸系统 ,与成人患者比较 ,病情较缓和 ,较少发生呼吸衰竭和侵犯呼吸系统以外的组织器官 ,预后良好 ;临床上应注意与传统的儿童非典型肺炎鉴别     

Colour Doppler imaging — a new method to differentiate torsion of the spermatic cord and epididymo-orchitis

A newborn boy with torsion of the spermatic cord and an 8-year-old boy with epididymitis were investigated by colour Doppler imaging (CDI). Due to torsion of the spermatic cord, no blood flow could be observed within the testis and the epididymis. In epididymitis blood flow was markedly increased. CDI seems to be useful for differentiating between the two disorders.     

Mastoiditis in children: a prospective, observational study comparing clinical presentation, microbiology, computed tomography, surgical findings and histology

The aim of this study was to obtain comprehensive data on clinical presentation, microbiology, computed tomography, surgical findings and histology in acute, sub-acute and chronic mastoiditis. We performed a prospective, observational study in children under 16 years of age presenting to our institution during the 2-year period beginning in April 2000. The children were examined and their condition treated in accordance with a standardized protocol elaborated by the paediatric, otolaryngology (ORL) and radiology departments. Thirty-eight patients were hospitalized (22 with acute mastoiditis, seven with sub-acute mastoiditis, nine with chronic mastoiditis). There were 30 complications present in 21 patients (55%). Streptococcus pyogenes was the most common pathogen (7/24 cases), followed by Streptococcus pneumoniae (4/24 cases). Mastoid surgery was performed in 29 patients. Histology of mastoid tissue revealed predominantly acute inflammation in two cases, mixed acute/chronic inflammation in 19 cases and predominantly chronic inflammation in seven cases. Radiologic data were evaluated retrospectively. Spiral, volume-based high-resolution (HR) computed tomography (CT) of the temporal bone had a sensitivity of 100%, specificity of 38%, positive predictive value (PPV) of 50% and negative predictive value (NPV) of 100% in detecting coalescence of mastoid trabeculae. Cranial CT with contrast had a sensitivity of 80%, specificity of 94%, PPV of 80% and NPV of 94% in identifying intra-cranial extension. Conclusion: histological evidence suggests that sub-acute/chronic infection underlies not only sub-acute and chronic mastoiditis, but most cases of acute mastoiditis as well. HR-CT of the temporal bone is effective in ruling out coalescence. Cranial CT is valuable in identifying intra-cranial extension. Cranial and HR-CT are recommended in the examination of children with mastoiditis.     

Spinal dysraphic anomalies; classification,presentation and management

Spinal dysraphism comprises an array of congenital anomalies of spinal cord development. Each of the dysraphic disorders can result in neurological, orthopaedic and urological dysfunction. This potentially confusing array of conditions is best understood from the embryological perspective. Whilst not all of these conditions are managed in the same way similar principles govern the initial investigation, multidisciplinary evaluation and long term follow up of these cases.     

Acute otitis media in infants younger than two months of age: microbiology,clinical presentation and therapeutic approach

BACKGROUND: Information on the causative agents of acute otitis media (AOM) in infants <2 months of age is limited. OBJECTIVES OF THE STUDY: To analyze the etiology, pathogen susceptibility patterns, clinical presentation and frequency of serious bacterial infections in infants <2 months of age with AOM and to determine the relationship between the organisms isolated systemically and those isolated from the middle ear fluid in the patients with serious bacterial infections in the presence of AOM. METHODS: The medical records of 137 infants <2 months of age with AOM who underwent tympanocentesis in the emergency room of Soroka University Medical Center between January 1, 1995, and May 30, 1999, were reviewed. The main variables analyzed included demography, frequency of serious bacterial infections, bacteriologic results, susceptibility patterns of the pathogens and clinical presentation. RESULTS: Median age was 38.7 +/- 13 days; 112 of 137 (82%) infants were hospitalized. Six (4%), 27 (20%), 46 (34%) and 58 (42%) episodes were recorded at age 0 to 2, 3 to 4, 5 to 6 and 7 to 8 weeks, respectively. Fever (temperature >38 degrees C) was present in 96 (70%) of the cases. Culture-negative (bacterial) meningitis was diagnosed in 3 cases. Blood and urine cultures were positive in 1 and 6 infants, respectively. None of the afebrile infants developed serious bacterial infection. One hundred twenty-two bacterial pathogens were isolated from the middle ear fluid of 109 of 137 (80%) patients: Streptococcus pneumoniae in 56 (46%), Haemophilus influenzae in 41 (34%), group A Streptococcus in 12 (10%), enteric gram-negative bacilli in 9 (7%), Moraxella catarrhalis in 3 (2%) and Streptococcus faecalis in 1 (1%). Eleven (20%) of the 56 S. pneumoniae isolates were nonsusceptible to penicillin. Serious bacterial infections were diagnosed in 6 of 137 (4%) patients. Whereas blood and urine grew pathogens typical for blood and urinary tract infections, the middle ear fluid isolates represented different pathogens usually isolated in AOM without any correlation between these 2 groups of pathogens. CONCLUSIONS: (1) Most cases of AOM in infants <2 months of age are caused by pathogens similar to those causing AOM in older children; (2) antibiotic resistance may already be present at early age and should be considered in the empiric treatment of AOM in infants <2 months of age; (3) the presence of AOM does not predict a higher risk for serious bacterial infections in afebrile and febrile infants <2 months of age.     

Acute mastoiditis: Clinical,microbiological, and therapeutic aspects

The charts of 73 children (31 girls, 42 boys) aged 4 months to 14 years (mean 4.5 years) with acute mastoiditis managed during a 16-year period were reviewed. Of the patients 36% were less than 24 months old. Retro-auricular swelling was described in 63 of the 73 children, tenderness in 59, erythema in 58, and protrusion of the auricle in 45. A pathological tympanic membrane was noted in 33% of the patients and fever in only 29%. Apart from local inflammation, the most frequent complaints and symptoms were otalgia (n=42), recent upper respiratory tract infections (n=22), and fever alone (n=22). A subperiosteal abscess was found in 36 patients, and CNS involvement in 5. Nearly half of the patients (48%) were on antibiotic therapy at admission. The isolation rates in bacterial cultures from subperiosteal aspirates (81%) and from mastoid mucosa (68%) were considerably higher than from blood cultures (14%) and were not influenced by previously administered antibiotics. Pneumococci (9/32) andStaphylococcus epidermidis (6/32) were the agents most often isolated. The incidence of the bacteria isolated from patients pre-treated with antibiotics differed from the incidence in patients not previously treated. In 24 patients (33%) the lesion healed with antibiotic therapy without mastoid surgery. Myringotomy and the insertion of a ventilation tube is indicated initially, if acute otitis media with effusion is found. In the absence of a subperiosteal abscess and of CNS involvement, a 48-hour trial of intravenous antibiotic therapy, directed also against staphylococci, is justified before mastoid surgery is considered.     

Childhood encephalitis in Sweden: Etiology, clinical presentation and outcome

Acute encephalitis is a relatively uncommon but potentially harmful CNS inflammation usually caused by infection. The diagnosis is difficult to establish and the etiology often remains unclear. Furthermore, the long-term prognosis of acute encephalitis in children is poorly described. In this study, we characterize childhood encephalitis from a Swedish perspective in regard to etiology, clinical presentation and sequele. We retrospectively studied all children (n=93) who were admitted for acute encephalitis at Karolinska University Hospital in Stockholm during 2000-2004. A confirmed etiological agent was identified in eight cases and a probable one in 37; in 48 cases no etiological agent could be found. Tick-borne encephalitis virus, enterovirus, respiratory syncytial virus, varicella zoster virus and influenza virus predominated and represented 67% of all the confirmed or probable etiologies. Encephalopathy was present in 80% of the children, 81% had fever, 44% had focal neurological findings, and seizures occurred in 40%. EEG abnormalities were seen in 90% and abnormal neuroimaging was present in 30%. The cerebrospinal fluid showed pleocytosis in 55%. There was no mortality, but 60% of the children had persisting symptoms at the time of discharge, 41% of which were moderate to severe. We conclude that the etiology of encephalitis among Swedish children is at large the same as in other European countries with similar vaccination programs. Fever and encephalopathy were seen in a majority of children and the most sensitive tool for making the diagnosis was EEG examination. Furthermore, many children display persisting sequele at discharge for which the strongest predictive factor was focal neurological findings at presentation.     

Bronchiolitis obliterans in children: clinical presentation, therapy and long-term follow-up

Aim:   To delineate the predisposing factors, clinical, radiological features and outcomes of bronchiolitis obliterans (BO) in children for minimising morbidity and mortality.
Methods:   Ten children who had BO from July 1995 to July 2005 were retrospectively reviewed at a tertiary paediatric facility in northern Taiwan.
Results:   Bronchiolitis obliterans complicated by infections, Stevens–Johnson syndrome was found in eight and two patients, respectively. In children with post-infectious BO, adenoviruses were the most common etiologic agents (7/8). Among them, six patients needed intensive management and five patients needed mechanical ventilation. All patients presented persistent dyspneic respirations and wheezing since the initial lung infection. Initial focal atelectasis ( n  = 3) on chest radiographs progressed to atelectasis/lobar collapse ( n  = 8) when the diagnosis of BO was made. After adequate supportive management, atelectatic bronchiectasis was the most common complication ( n  = 5).
Conclusion:   Severe adenovirus bronchiolitis and/or pneumonia appear to have higher risk of development of BO in children. In order to minimise associated complications of BO, meticulous respiratory care for preventing pulmonary collapse may be considered in such instances.