Bilateral meconium hydrocele An uncommon case

Transcription

1 Bilateral meconium hydrocele An uncommon case Didem Turcan 1, Evrim Yılmaz 1, Deniz Arık 1, Baran Tokar 2 1 Department of Pathology, 2 Department of Pediatric Surgery,

2 Introduction Meconium hydrocele is a rare benign reason of scrotal masses in newborns caused by meconium leakage due to in utero intestinal perforation Inspissated meconium associated with cystic fibrosis, bowel atresia, volvulus, vascular insufficiency, imperforated anus, hyperplastic lymphoid tissue and colonic aganglionosis are accused of causing perforation, but sometimes perforation can be idiopathic 2

3 Introduction In most cases, the intestinal perforation had healed without obvious sequelae before birth The scrotal mass consistency depends on the perforation time; it is soft if the perforation was occurred recently at birth but it is hard and calcified if the perforation was occurred earlier Herein, we present a bilateral meconium hydrocele in a new-born and its histopathological features 3

4 Case A 4 days old full term male baby Restlessness and reluctance feeding Voiding and defecation were normal since birth Uneventful pregnancy 4

5 Case Firm scrotum on palpation No signs of tenderness or erythema No other abnormality on physical examination Tumour markers were unremarkable Scrotal ultrasound demonstrated intrascrotal extratesticular anechoic mass including millimetric calcifications, measuring 2,5 cm in diameter on the posterior side of both testes Paratesticular masses Normal testes 5

6 Case Vascular flow on Doppler Calcification was not detected on abdominal X-ray A fibrous pseudotumor was suspected on scrotal MRI 6

7 Case Bilateral inguinoscrotal exploration was done when the patient was at the age of one month Hydrocele containing meconium inside and on the wall was found on the both sides He also had bilateral inguinal hernia having connection to the hydrocele Hernia sac also had meconium inside Both testes were intact Hydrocele wall excision, hernia repair and orchiopexy were performed on both sides 7

8 Case Gross pathologic findings: Oval shaped lump with variable consistency from soft to firm Yellowish green cut surface 4x1.5x0.8 cm diameters, right side 2x1x1 cm diameters, left side Microscopic examination: Fibromyxoid connective tissue containing mucin lakes, dystrophic calcifications, scattered hemosiderin-laden macrophages, bile pigment, lanugo hair 8

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11 Case These histopathological findings were consistent with meconium hydrocele The patient is healty one year after surgery 11

12 Discussion Fetal peristalsis and meconium Meconium is sterile, greenish, viscous intestinal product If meconium enters to the peritoneal cavity, it provokes a sterile inflammatory reaction with calcification and fibrosis meconium peritonitis 12

13 Discussion Extravasated meconium patent processus vaginalis scrotum scrotal mass foreign body reaction fibrosis and calcification soft hydrocele transforms into hard "tumour-like" lesion Testicular involvement of the affected side is rare Different terminologies are used for this disease: Meconium hydrocele Meconium periorchitis Scrotal calcification due to meconium peritonitis Meconium in the processus vaginalis Meconium granulomas 13

14 Discussion The diagnosis time varies from birth to 20 months of age, average time of diagnosis is 1 month In our case, bilateral hydrocele were identified at 4 days old baby 14

15 Discussion Demonstration of scrotal and peritoneal calcifications caused by healed meconium peritonitis on radiologic studies are pathognomonic Blood flow is not observed on Doppler studies When the characteristic radiologic findings are seen and the clinical diagnosis can be made; surgery is not necessary mostly due to spontaneous regression of the mass 15

16 Discussion If there is suspicion for other scrotal masses with calcifications, surgical exploration is mandatory to confirm the diagnosis Testicular teratomas Gonadoblastomas Leydig cell tumors Testicular microlithiasis Fibrous pseudotumors with calcifications Calcifying organized hematoma Metabolic calcinosis Metastatic neuroblastoma Yolk sac tumors Unless the mass establishes malignant, the testes must be saved 16

17 Discussion Multiple small nodules along the spermatic cord or bulky solitary paratesticular mass Fibrous capsule Yellowish green colour Cut surface is gelatinous and faintly lobulated 17

18 Discussion Microscopic characteristics Dystrophic calcifications, foreign body giant cells, phagocytic histiocytes in the loose fibromyxoid connective tissue Throughout the connective tissue fibroblasts, hemosiderin pigment and the remnants of meconium; lanugo hair, desquamated epithelial cells, bile salt and pigments are seen 18

19 Conclusion When a scrotal mass is discovered in infants and young children, this rare benign entity should be considered to decide on the choice of treatment modalities 19

20 References 1. Algaba, F., Mikuz, G., Boccon-Gibod, L., Trias, I., Arce, Y., Montironi, R.,... & Lopez-Beltran, A. (2007). Pseudoneoplastic lesions of the testis and paratesticular structures. Virchows Archiv, 451(6), Dehner, L. P., Scott, D., & Stocker, J. T. (1986). Meconium periorchitis: a clinicopathologic study of four cases with a review of the literature. Human pathology, 17(8), Ring, K. S., Axelrod, S. L., Burbige, K. A., & Hensle, T. W. (1989). Meconium hydrocele: an unusual etiology of a scrotal mass in the newborn. The Journal of urology, 141(5), Srivastava, P., Gangopadhyay, A. N., Gupta, D. K., Kumar, V., Sharma, S. P., Upadhyaya, V. D., & Jaiman, R. (2011). Giant meconium hydrocele: a rare presentation of antenatal gastrointestinal perforation. Journal of paediatrics and child health, 47(3), Olnick, H. M., & Hatcher, M. B. (1953). Meconium peritonitis. Journal of the American Medical Association, 152(7), Forouhar, F. (1982). Meconium peritonitis: pathology, evolution, and diagnosis. American journal of clinical pathology, 78(2), Herman, T. E., & Siegel, M. J. (2004). Meconium periorchitis. Journal of perinatology, 24(1), Rekhi, H. S., Mittal, S. K., Mannem, S. R., Arora, S., Seth, K., Pakkiri, S.,... & Mathur, M. (2016). An atypical case of meconium periorchitis as paratesticular mass in a neonate. Clinical case reports, 4(9), Kalra, P., & Radhakrishnan, J. (2006). Meconium periorchitis. Urology, 68(1), Brown-Harrison, M. C., Harrison, A. M., Reid, B. S., & Cartwright, P. C. (2000). Meconium Periorchitis A Cause of Scrotal Mass in the Newborn. Clinical pediatrics, 39(3),