By Adenike Animasaun
Pediatric Emergency Medicine Fellow
Children’s National Hospital
Washington, DC
Chief Complaint
Penile and scrotal swelling for “months”
History
15 y.o. previously healthy male presenting with chronic penile and scrotal swelling. Patient has been having swelling without pain for the past few months, he is unable to say exactly when it started. The swelling has increased gradually over the past 2-3 months. He went to his PMD today due to having blisters on the scrotum that popped on Saturday with clear fluid drainage. Denies pain of the penis/scrotum or difficulty urinating. No fever, abdominal pain, vomiting, constipation, diarrhea, dysuria, hematuria, penile drainage/discharge, or trauma to the area. No difficulty walking. No swelling anywhere else. No medical or surgical history. No daily medication use. No known drug allergies. Up to date on vaccines.
- H: Lives at home with mom, dad, and sister. Feels safe at home.
- E: Currently in high school
- A: Plays football
- D: Denies drug, alcohol, tobacco use
- S: Never been sexually active
- S: Denies SI/HI
Physical with vital signs
T37.4 C, HR 80, RR 20, BP 111/75, SpO2 99% on RA
General
Well appearing. Alert. Shy and soft spoken but interactive. Cooperative.
Skin
Warm. Dry. Intact. No rashes
Eye
Pupils are equal, round and reactive to light.
Ears, nose, mouth, and throat
No pharyngeal erythema or exudate. Moist mucosal membranes. Tympanic membranes clear.
Cardiovascular
Regular rate and rhythm. No murmur. No gallop. Normal peripheral perfusion. Capillary refill <2 sec.
Respiratory
Lungs are clear to auscultation bilaterally. Respirations are non-labored. Breath sounds are equal.
Gastrointestinal
Soft. Non-distended. Normal bowel sounds. Non-tender., No guarding or rebound. No palpable masses. No hepatosplenomegaly. Multiple large anal skin tags on the dorsal surface of the anus. No fissures.
Genitourinary
Significant swelling of the bilateral scrotum and penis. ~1cm blister on anterior aspect of right scrotum. No tenderness of the scrotum or penis. No overlying erythema, no pustules, no ulcerations
Neurological
No focal neurologic deficits
Urgent Care work up (labs, images, meds etc)
A urinalysis was obtained and resulted as: WBC <1, RBC 1, negative ketone, negative LE, negative nitrite. CBC and CMP were normal.
Brief one liner about disposition (admitted, transferred, discharged home with referral)
Patient was referred to the ED for a scrotal ultrasound and labs. ESR, CRP, beta hCG, uric acid and LDH were all normal. Ultrasound found “Nonspecific scrotal sac/penile soft tissue thickening without discrete cystic/solid mass or fluid collection. Normal sonographic appearance of bilateral testicles”. Urology consulted for possible lymphatic malformation at which time they had low suspicion for lymphatic malformation and recommend GI consult. GI consulted and upon further examination found presentation and physical exam findings concerning for possible cutaneous manifestation of Crohn’s disease. They recommend outpatient follow up and dermatology follow up for blister on scrotum.
Ultimate Diagnosis
Crohn’s Disease with primarily cutaneous manifestations
At least 2-3 learning pearls about the diagnosis
- There are few reports of urogenital metastatic Crohn’s disease in the pediatric population. Metastatic Crohn’s disease has the potential to exist in isolation of gastrointestinal findings. Urogenital manifestations of Crohn’s disease in children include penoscrotal swelling, erythema, plaques, or ulcers in males. In females, vulvar swelling, fissures, and ulcers are common urogenital manifestations.
- About 6% of children with Crohn’s disease first presented with extraintestinal manifestations. In the pediatric population, the most common presentation of metastatic Crohn’s disease is chronic or recurrent penile and/or scrotal swelling in boys.
- Children who present in the absence of any gastrointestinal symptoms often have difficulties in receiving the correct diagnosis, leading to delayed and/or inappropriate management. The fact that persistent penile swelling is an uncommon pediatric condition, along with its many different etiologies, means it can be difficult for a patient who first presents to be correctly diagnosed with metastatic Crohn’s disease of the genitourinary tract.
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