Henoch-Schönlein Purpura With Orchitis
An 8-year-old previously healthy boy presented to the emergency department (ED) with an acute painful scrotum. There was no history of dysuria, urgency, hematuria, abdominal pain, vomiting, or genital trauma.
On examination, the child had stable vital signs. Ecchymosis and swelling of the left hemiscrotum (A) was noted. The left testicle was mildly tender to palpation. Both testicles were descended and normal in position. Cremasteric reflex was elicited bilaterally. Skin examination revealed a petechial purpuric rash on his lower extremities, buttocks, and groin region (B). The remaining examination findings were essentially normal.
The parents subsequently reported that the boy had some swelling around his ankles and that the rash had been present for the past 2 days.
Urinalysis results were normal. A Doppler ultrasound examination demonstrated a hyperemic left testicle with left scrotal wall thickening, suggestive of orchitis, and no evidence of torsion.
Henoch-Schönlein purpura (HSP) with orchitis was diagnosed. The child was discharged and scheduled for urology follow-up as an outpatient.
HSP, a systemic vasculitis of unknown cause, usually involves the skin, GI tract, kidneys, and joints. The first case of male genital involvement in this syndrome was reported by Allen and colleagues1 in 1960. Scrotal involvement, although uncommon in HSP, may manifest as purpuric rash, edema, or scrotal swelling and pain—which can be unilateral or bilateral. Vasculitis is the underlying cause of testicular pain and swelling in HSP.
In the majority of patients, the diagnosis of HSP is established before the onset of scrotal complaints; however, rarely an acute scrotum can be the initial presenting complaint and hence can be misdiagnosed as testicular torsion.
Treatment is mainly supportive. Corticosteroids can be considered in patients with severe scrotal edema. The condition is self-limited and carries a favorable prognosis, with no effect on fertility. Pediatric practitioners and ED physicians should include HSP in the differential diagnosis of acute scrotum.
1. Allen DM, Diamond LK, Howell DA. Anaphylactoid purpura in children (Schönlein-Henoch syndrome): review with a follow-up of the renal complications. AMA J Dis Child. 1960;99:833-854.