0022-534 7/92/14 74-1085$03,00/0 VoL 147, 1085-1086, April 1992
THE JOURNAL OF UROLOGY
Printed in U8-A
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATlON, INC,
VENOMOUS BITES TO THE EXTERNAL GENITALIA: AN UNUSUAL CAUSE OF ACUTE SCROTUM MICHAEL E. MORAN, JEFFREY T. EHRETH
AND
GEORGE W. DRACH
From the Department of Urology, University of California, Davis, Sacramento, California, and Department of Surgery, Section of Urology, University of Arizona, Tucson, Arizona
ABSTRACT
The acute scrotum generates a long list of differential diagnoses. An unusual etiology includes insect envenomation, which typically is an acute process with rapid onset of symptomatologies. Two patients with genital envenomation are reported. We review the reported cases at our institution with all types of bites and stings. Symptoms of pain and pruritus, and signs of ecchymosis and edema preceding exfoliating dermatitis were evident in both cases. Mild analgesics and antihistamines promoted resolution in each instance. KEY WORDS:
acute disease, scrotum, insect bites and stings, venoms
Envenomations are not uncommon in the United States or the world. A formidable number of creatures exist that are classified as venomous. 1 Fortunately, the genitalia are infrequently involved by the bite or sting of such animals, probably because clothing acts as a barrier to such events. The clinical scenario of testicular torsion must be considered with any presentation of acute scrotal swelling, including infections of the testis or spermatic cord (funiculitis, deferentitis, epididymitis or orchitis), scrotal infections (Fournier's gangrene, scrotal cellulitis, sebaceous cysts, ruptured appendicitis or diverticular disease), hernia, hydrocele, hematocele, chylocele, pyocele, spermatocele and torsed spermatocele, tumor (testicular or paratesticular), testicular torsion (intravaginal, extravaginal or undescended), torsion of testicular appendages, idiopathic fat necrosis, idiopathic scrotal edema, scrotal panniculitis, Henoch-Schonlein purpura, trauma and insect bite. We recently treated 2 patients with scrotal envenomation who presented to the emergency department with the differential diagnosis of acute scrotum. In 1 instance the arthropod vector was not noted or identified, whereas the second insect was confirmed. Lack of identification is a frequent occurrence in envenomations, making accurate statistical accrual of the responsible animal vectors difficult. 2 CASE HISTORIES
An 11-year-old boy presented acutely to the emergency department 24 hours after working in the fields of central Virginia. Thereafter he noticed increasing pain, swelling and pmritus of the right hemiscrotum. Pain began to ascend into the right inguinal area. The patient was afebrile. Urinalysis was unremarkable and the hemogram was within normal limits. At examination there were 3 areas of raised puncta: 1 on the right upper hemiscrotum, 1 on the right upper medial thigh and 1 in the left inguinal area (fig. 1). The scrotum was erythematous and there was substantial subcutaneous ecchymosis, which extended cranially into the right inguinal canal up to the external ring. No groin adenopathy existed. Magnification revealed the puncta to have small bilateral wounds consistent with penetration of the chelicerae of a spider. The patient had a history of lower abdominal cramps during the preceding 24 hours, which had resolved before presentation. Oral diphenhydramine hydrochloride was begun and the symptomatic pruritus improved. He required no further medications. Tetanus prophylaxis was current, since it had been given recently at school. By day 4 after envenomation the edema receded, and epidermal exfoliation and pruritis occurred. Both problems were minor and required no further therapy. Accepted for publication September 13, 1991.
Case 2. A 6-year-old boy presented to the emergency department after awakening to a sudden painful sensation in the scrotum and right groin. The mother immediately came to the aid of the child and noticed a 10 mm "brownish-black" insect with a "spade-like" snout. It was engorged with blood when killed. She did not bring the insect with her to the emergency department. The mother noticed progression of scrotal pain, swelling, pruritus and ecchymosis, prompting the emergency room visit. The child appeared well with no systemic manifestations of envenomation other than a temperature of 38.2C orally. He would not void for fear of pain. At examination he had a circumcised phallus with a poorly circumscribed 10 mm. area of dark ecchymosis on the right hemiscrotum and right inguinal area (fig. 2). On magnification no paired puncture holes could be identified. The complete blood count showed a leukocytosis of 19.3 K. but no left shift or lymphocytosis. Diagnosis was a kissing bug bite (Triatoma protracta) and the child was admitted to the hospital for analgesia and observation. Because these insect bites may be associated with epidermal necrosis he was given antibiotics. During the ensuing 12 hours the edema progressed, the ecchymosis regressed and epidermolysis developed. The pain subsided and the patient was discharged from the hospital the next day. Tetanus prophylaxis was not necessary because the immunizations were current. DISCUSSION
Genital envenomations have been rarely reported or alluded to during the last 20 years. 2 They have been believed to have the potential for greater systemic manifestations than do extremity envenomations. 2 Our 2 patients do not reflect this tendency but the series is small. Case 1 was not difficult to diagnose given the history and physical findings despite no identified arthropod vector. The differential diagnosis presented no problems in patient 2 in whom the arthropod vector was identified by a reliable witness. Both patients had difficult testicular examinations because of the degree of scrotal edema but no tenderness of the testes could be appreciated. Both patients had normal Doppler testicular pulses. No other ancillary studies were needed. Magnification of the. erythematous and edematous scrotum was helpful in case 1 to identify the paired puncture wounds of chelicerae. In both patients resolution of edema was associated with epidermal exfoliation. Scrotal elevation was our only local treatment. Oral antihistamines helped to control the edema and pruritus. No intravenous calcium or muscle relaxants were required in either patient but these may be needed if muscle cramps, nausea or vomiting ensue. Tetanus prophylaxis is suggested in cases of arthropod
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FIG. 1. Case 1, presumed spider envenomation. Arrows indicate 3 puncture areas in right hemiscrotum, right upper thigh and left inguinal area.
necrotizing local skin conditions that may need debridement and skin grafting. 3 Identification of the vector of envenomation is important for the accurate management of these patients. Although both of our patients had mild manifestations of envenomation, there have been reported deaths from insect venoms. Some are the anaphylactoid types seen with hymenopteran insects. The kissing bug noted in case 2 has a low but definite risk of local wound necrosis. Since we knew the insect in this instance this child was started on antibiotics until the clinical scenario began to resolve after 12 hours. The age of the patient bitten or stung appears to have a profound effect on the clinical course after envenomation. 4 The size and overall health of an individual may have a role in the clinical response to the venoms. Prior immunity may also have a role. It has been noted that individuals wholive iri eooemfo areas often have less severe reactions than people visiting an area that is habitat for such creatures. 2 Finally, patients with arthropod envenomations allow interesting etiological differentials of the acute scrotum. These occurrences are rare. The University of Arizona is a tertiary care facility with a large experience with all types of envenomations. We reviewed 8 years of inpatient and outpatient presentations with a variety of envenomations from Arachnida, Hymenoptera, venomous snakes, lizards, scorpions, centipedes, caterpillars and 1 reported case of a marine animal sting. We had 93 inpatient admissions and 109 outpatient emergency room visits for envenomations. These 2 patients represent the only genital envenomations (1 %). In conclusion, the hallmark feature in both of our patients was edema that preceded pruritus and ecchymosis. Epidermolysis was noted subsequently in both cases. Toxic manifestations were noted in the kissing bug envenomation with a temperature to 38.2C and leukocytosis. Both patients showed the tendency for more than 1 bite, with the scrotum and groin being bitten. Both cases were easily diagnosed. Magnified integumental examination was helpful to identify puncture sites. However, the full differential diagnosis must be remembered, since several patients with synchronous intrascrotal processes have been reported. 5 A thorough and systematic approach to the child with such a process can virtually assure the astute practitioner of a proper diagnosis. REFERENCES
FIG. 2. Case 2, Triatoma proctracta (kissing bug) envenomation. Note well circumscribed area of ecchymosis. Arrow indicates region of bite.
envenomation. 2 Edema can progress to impressive proportions as occurred in case 2. Both of our patients were circumcised and no compartment syndrome developed but the possibility of glans ischemia is theoretically possible especially in uncircumcised children. Brown recluse spiders are noted to produce
1. Russell, F. E.: Venomous animal injuries. Curr. Prob. Ped., 3: 1, 1973.
2. Wong, R. C., Hughes, S. E. and Voorhees, P. J.: Spider bites. Arch. Dermatol., 123: 98, 1987. 3. Wasserman, G. S. and Anderson, P. C.: Loxoscelism and necrotic arachnidism. J. Toxicol. Clin. Toxicol., 21: 451, 1983-84. 4. Maretic, Z.: Latrodectism: variations in clinical manifestations provoked by Latrodectus species of spiders. Toxicon, 21: 457, 1983. 5. Loh, H. S. and Jalan, 0. M.: Testicular torsion in HenochSchonlein syndrome. Brit. Med. J., 2: 96, 1974.
THE JOURNAL OF UROLOGY
Printed in U8-A
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATlON, INC,
VENOMOUS BITES TO THE EXTERNAL GENITALIA: AN UNUSUAL CAUSE OF ACUTE SCROTUM MICHAEL E. MORAN, JEFFREY T. EHRETH
AND
GEORGE W. DRACH
From the Department of Urology, University of California, Davis, Sacramento, California, and Department of Surgery, Section of Urology, University of Arizona, Tucson, Arizona
ABSTRACT
The acute scrotum generates a long list of differential diagnoses. An unusual etiology includes insect envenomation, which typically is an acute process with rapid onset of symptomatologies. Two patients with genital envenomation are reported. We review the reported cases at our institution with all types of bites and stings. Symptoms of pain and pruritus, and signs of ecchymosis and edema preceding exfoliating dermatitis were evident in both cases. Mild analgesics and antihistamines promoted resolution in each instance. KEY WORDS:
acute disease, scrotum, insect bites and stings, venoms
Envenomations are not uncommon in the United States or the world. A formidable number of creatures exist that are classified as venomous. 1 Fortunately, the genitalia are infrequently involved by the bite or sting of such animals, probably because clothing acts as a barrier to such events. The clinical scenario of testicular torsion must be considered with any presentation of acute scrotal swelling, including infections of the testis or spermatic cord (funiculitis, deferentitis, epididymitis or orchitis), scrotal infections (Fournier's gangrene, scrotal cellulitis, sebaceous cysts, ruptured appendicitis or diverticular disease), hernia, hydrocele, hematocele, chylocele, pyocele, spermatocele and torsed spermatocele, tumor (testicular or paratesticular), testicular torsion (intravaginal, extravaginal or undescended), torsion of testicular appendages, idiopathic fat necrosis, idiopathic scrotal edema, scrotal panniculitis, Henoch-Schonlein purpura, trauma and insect bite. We recently treated 2 patients with scrotal envenomation who presented to the emergency department with the differential diagnosis of acute scrotum. In 1 instance the arthropod vector was not noted or identified, whereas the second insect was confirmed. Lack of identification is a frequent occurrence in envenomations, making accurate statistical accrual of the responsible animal vectors difficult. 2 CASE HISTORIES
An 11-year-old boy presented acutely to the emergency department 24 hours after working in the fields of central Virginia. Thereafter he noticed increasing pain, swelling and pmritus of the right hemiscrotum. Pain began to ascend into the right inguinal area. The patient was afebrile. Urinalysis was unremarkable and the hemogram was within normal limits. At examination there were 3 areas of raised puncta: 1 on the right upper hemiscrotum, 1 on the right upper medial thigh and 1 in the left inguinal area (fig. 1). The scrotum was erythematous and there was substantial subcutaneous ecchymosis, which extended cranially into the right inguinal canal up to the external ring. No groin adenopathy existed. Magnification revealed the puncta to have small bilateral wounds consistent with penetration of the chelicerae of a spider. The patient had a history of lower abdominal cramps during the preceding 24 hours, which had resolved before presentation. Oral diphenhydramine hydrochloride was begun and the symptomatic pruritus improved. He required no further medications. Tetanus prophylaxis was current, since it had been given recently at school. By day 4 after envenomation the edema receded, and epidermal exfoliation and pruritis occurred. Both problems were minor and required no further therapy. Accepted for publication September 13, 1991.
Case 2. A 6-year-old boy presented to the emergency department after awakening to a sudden painful sensation in the scrotum and right groin. The mother immediately came to the aid of the child and noticed a 10 mm "brownish-black" insect with a "spade-like" snout. It was engorged with blood when killed. She did not bring the insect with her to the emergency department. The mother noticed progression of scrotal pain, swelling, pruritus and ecchymosis, prompting the emergency room visit. The child appeared well with no systemic manifestations of envenomation other than a temperature of 38.2C orally. He would not void for fear of pain. At examination he had a circumcised phallus with a poorly circumscribed 10 mm. area of dark ecchymosis on the right hemiscrotum and right inguinal area (fig. 2). On magnification no paired puncture holes could be identified. The complete blood count showed a leukocytosis of 19.3 K. but no left shift or lymphocytosis. Diagnosis was a kissing bug bite (Triatoma protracta) and the child was admitted to the hospital for analgesia and observation. Because these insect bites may be associated with epidermal necrosis he was given antibiotics. During the ensuing 12 hours the edema progressed, the ecchymosis regressed and epidermolysis developed. The pain subsided and the patient was discharged from the hospital the next day. Tetanus prophylaxis was not necessary because the immunizations were current. DISCUSSION
Genital envenomations have been rarely reported or alluded to during the last 20 years. 2 They have been believed to have the potential for greater systemic manifestations than do extremity envenomations. 2 Our 2 patients do not reflect this tendency but the series is small. Case 1 was not difficult to diagnose given the history and physical findings despite no identified arthropod vector. The differential diagnosis presented no problems in patient 2 in whom the arthropod vector was identified by a reliable witness. Both patients had difficult testicular examinations because of the degree of scrotal edema but no tenderness of the testes could be appreciated. Both patients had normal Doppler testicular pulses. No other ancillary studies were needed. Magnification of the. erythematous and edematous scrotum was helpful in case 1 to identify the paired puncture wounds of chelicerae. In both patients resolution of edema was associated with epidermal exfoliation. Scrotal elevation was our only local treatment. Oral antihistamines helped to control the edema and pruritus. No intravenous calcium or muscle relaxants were required in either patient but these may be needed if muscle cramps, nausea or vomiting ensue. Tetanus prophylaxis is suggested in cases of arthropod
1085
1086
MORAN, EHRETH AND DRACH
FIG. 1. Case 1, presumed spider envenomation. Arrows indicate 3 puncture areas in right hemiscrotum, right upper thigh and left inguinal area.
necrotizing local skin conditions that may need debridement and skin grafting. 3 Identification of the vector of envenomation is important for the accurate management of these patients. Although both of our patients had mild manifestations of envenomation, there have been reported deaths from insect venoms. Some are the anaphylactoid types seen with hymenopteran insects. The kissing bug noted in case 2 has a low but definite risk of local wound necrosis. Since we knew the insect in this instance this child was started on antibiotics until the clinical scenario began to resolve after 12 hours. The age of the patient bitten or stung appears to have a profound effect on the clinical course after envenomation. 4 The size and overall health of an individual may have a role in the clinical response to the venoms. Prior immunity may also have a role. It has been noted that individuals wholive iri eooemfo areas often have less severe reactions than people visiting an area that is habitat for such creatures. 2 Finally, patients with arthropod envenomations allow interesting etiological differentials of the acute scrotum. These occurrences are rare. The University of Arizona is a tertiary care facility with a large experience with all types of envenomations. We reviewed 8 years of inpatient and outpatient presentations with a variety of envenomations from Arachnida, Hymenoptera, venomous snakes, lizards, scorpions, centipedes, caterpillars and 1 reported case of a marine animal sting. We had 93 inpatient admissions and 109 outpatient emergency room visits for envenomations. These 2 patients represent the only genital envenomations (1 %). In conclusion, the hallmark feature in both of our patients was edema that preceded pruritus and ecchymosis. Epidermolysis was noted subsequently in both cases. Toxic manifestations were noted in the kissing bug envenomation with a temperature to 38.2C and leukocytosis. Both patients showed the tendency for more than 1 bite, with the scrotum and groin being bitten. Both cases were easily diagnosed. Magnified integumental examination was helpful to identify puncture sites. However, the full differential diagnosis must be remembered, since several patients with synchronous intrascrotal processes have been reported. 5 A thorough and systematic approach to the child with such a process can virtually assure the astute practitioner of a proper diagnosis. REFERENCES
FIG. 2. Case 2, Triatoma proctracta (kissing bug) envenomation. Note well circumscribed area of ecchymosis. Arrow indicates region of bite.
envenomation. 2 Edema can progress to impressive proportions as occurred in case 2. Both of our patients were circumcised and no compartment syndrome developed but the possibility of glans ischemia is theoretically possible especially in uncircumcised children. Brown recluse spiders are noted to produce
1. Russell, F. E.: Venomous animal injuries. Curr. Prob. Ped., 3: 1, 1973.
2. Wong, R. C., Hughes, S. E. and Voorhees, P. J.: Spider bites. Arch. Dermatol., 123: 98, 1987. 3. Wasserman, G. S. and Anderson, P. C.: Loxoscelism and necrotic arachnidism. J. Toxicol. Clin. Toxicol., 21: 451, 1983-84. 4. Maretic, Z.: Latrodectism: variations in clinical manifestations provoked by Latrodectus species of spiders. Toxicon, 21: 457, 1983. 5. Loh, H. S. and Jalan, 0. M.: Testicular torsion in HenochSchonlein syndrome. Brit. Med. J., 2: 96, 1974.
