Letters to the Editor
To the Editor:
Qvist1 first reported acute idiopathic scrotal edema (AISE) in 1956. No specific cause has been identified. Here, we discuss 2 cases of AISE caused by acute Epstein–Barr viral (EBV) infection.
A 13-year-old male and a 6-year-old boy visited our hospital because of penile, scrotal and perineal swelling. Both of them reported no trauma to the perineal area and had never experienced an allergic reaction to any medications. Laboratory tests including urinalysis were normal. Penile and scrotal color Doppler ultrasonography (US) of the first case revealed diffuse swelling of the penile, scrotal and bilateral inguinal wall soft tissue with hypervascularity in addition to small nodules in both inguinal areas. Scrotal US of the 6-year-old boy showed multiple enlarged lymph nodes in the right inguinal area and diffuse soft tissue swelling of the scrotal and perineal wall. Serologic testing for cytomegalovirus and EBV were performed in both cases, which revealed the presence of immunoglobulin G (IgG) and immunoglobulin M (IgM) to the viral capsid antigen (VCA) of EBV, indicating recent EBV infection. Their symptoms disappeared spontaneously within a few days.
The clinical manifestations of AISE include scrotal edema without tenderness.2 Penile, perineal and inguinal involvement occur in 20%, 42% and 67% of patients with AISE, respectively. It can be easily diagnosed with ultrasound examination. Edematous thickening and increased vascularity are characteristic of AISE.3 Enlargement and increased vascularity of the inguinal lymph nodes are commonly detected by US.3 There are many hypothesized etiologies; however, the cause of AISE has not been identified.2
EBV infection in young children is usually asymptomatic or resembles other febrile infections. The most common site of lymphadenopathy is the anterior and posterior cervical areas, and sometimes axillary and inguinal lymph nodes can be affected. Antibodies to the EBV nuclear antigen, the early antigen and the VCA are most useful for diagnosis. Acute EBV infection is characterized by rapid elevation of IgM and IgG antibody responses to VCA and a detectable IgG response to early antigen. Therefore, the IgM-VCA test is the most specific serologic test for diagnosis of acute EBV infection.4
The clinical features of our cases were similar to those of testicular torsion or acute epididymitis. However, we were able to diagnose AISE by scrotal US without difficulty. We suspected an unusual infection as the cause of scrotal edema, and incidentally we found that IgM-VCA was elevated in both cases, confirming acute EBV infection. According to previous reports, acute EBV infection in childhood may cause inguinal lymphadenopathy, which is consistent with the clinical manifestations in our cases. Therefore, we suspect that acute EBV infection caused our patients’ acute scrotal and perineal edema. Based on our cases and previous reports about EBV, we suggest that acute EBV infection is the cause of AISE.
Sang Hyub Lee, MD, PhD
Department of Urology
Kyung Hee University Medical Center
Dong-Gi Lee, MD, PhD
Koo Han Yoo, MD, PhD
Seung-Kwon Choi, MD
Gyeong Eun Min, MD, PhD
Hyung-Lae Lee, MD, PhD
Department of Urology
Kyung Hee University Hospital at Gandong
1. Qvist O. Swelling of the scrotum in infants and children, and non-specific epididymitis; a study of 158 cases. Acta Chir Scand. 1956;110:417–421
2. Klin B, Lotan G, Efrati Y, et al. Acute idiopathic scrotal edema in children--revisited. J Pediatr Surg. 2002;37:1200–1202
3. Grainger AJ, Hide IG, Elliott ST. The ultrasound appearances of scrotal oedema. Eur J Ultrasound. 1998;8:33–37
4. Jenson HB. Epstein-Barr virus. Pediatr Rev. 2011;32:375–383; quiz 384