Neonatal epididymo-orchitis caused by Salmonella: A case of successful non-surgical management

Abstract

Neonatal epididymo-orchitis (EO) is a rare condition, particularly when caused by S almonella , a pathogen typically associated with gastroenteritis. We present the case of a 15-day-old male who developed right-sided scrotal swelling and erythema. Scrotal ultrasound confirmed EO without signs of torsion or abscess. Further investigation revealed potential Salmonella exposure from feeding bottles, and stool PCR confirmed the diagnosis. The patient responded well to antibiotics, avoiding surgical intervention. This case highlights the rarity of Salmonella EO in neonates and the value of early imaging, thorough history-taking, and environmental exposure assessment in guiding conservative management and avoiding surgery.

1 Introduction

Acute scrotal swelling in neonates presents a diagnostic challenge due to its broad differential, ranging from benign conditions to surgical emergencies like testicular torsion. Among the rarer causes of acute scrotum in infants is epididymo-orchitis (EO), especially when it occurs secondary to an uncommon pathogen such as Salmonella . While most Salmonella infections manifest as gastroenteritis, extraintestinal involvement such as in the genitourinary tract, is rare but documented in the pediatric population. Neonatal EO remains an uncommon presentation, with only a few cases of Salmonella -related infections reported in the literature.

In this report, we present a unique case of Salmonella EO in a 15-day-old male infant. This case highlights the importance of non-invasive diagnostics, thorough history-taking, and the need to consider uncommon infectious etiologies in the differential diagnosis of neonatal scrotal swelling to prevent potential unnecessary surgical intervention.

2 Case presentation

A 15-day-old, 3.7-kg term male, born via cesarean section due to maternal polyhydramnios, presented to the emergency department with a one-day history of right-sided scrotal swelling, redness, and tenderness ( Fig. 1 ). The parents initially noted a red rash on the scrotum, which they treated with topical diaper rash cream; however, the symptoms progressed, with increased scrotal swelling and erythema. They also observed fussiness during diaper changes and a firm texture to the right hemi-scrotum. The patient’s neonatal course was otherwise uncomplicated, with routine vaccinations received. He was formula-fed , and his medical history was unremarkable, with no recent fevers, trauma, or sick contacts. In the days leading up to presentation, the parents reported irregular bowel movements, describing an increase in diaper changes, with 6-8 stools per 24-h period. They characterized the stools as mucous diarrhea. The persistence of these abnormal bowel patterns, fussiness with diaper changes, and the lack of response to over-the-counter topical treatment ultimately led them to seek emergency care.

On examination, the patient was afebrile and hemodynamically stable. Physical examination revealed a swollen, erythematous, indurated, and tender right hemi-scrotum. The left testicle was unremarkable except for mild hydrocele. Abdominal examination revealed a flat, non-distended abdomen with normal bowel sounds and no palpable tenderness, masses, or hernias. Scrotal ultrasound revealed right-sided EO with associated enlargement and hyperemia of the epididymis and spermatic cord, a small complex hydrocele, and thickening of the scrotal wall ( Fig. 2 ). There was no abscess identified and no evidence of testicular torsion. Initial laboratory tests showed a white blood cell count (WBC) of 13.8 with neutrophil predominance (62.1 %) and elevated inflammatory markers, including procalcitonin (3.83) and C-reactive protein (1.3). Urinalysis revealed only trace protein and was otherwise within normal limits. Given the negative urinalysis, a renal and bladder ultrasound was performed to rule out congenital abnormalities that could cause chemical epididymitis, which returned normal results.

In the context of evaluating for late-onset sepsis, the patient underwent a blood culture, urine culture, and lumbar puncture with cerebrospinal fluid (CSF) cultures. Empirical antibiotics—ampicillin and gentamicin—were initiated. Due to concern for localized cellulitis, clindamycin was also added. Subsequent CSF analysis showed no pleocytosis, and molecular testing was negative for pathogens. Given the history of suspected bacteremia and unilateral orchitis in a neonate, an infectious disease (ID) specialist recommended empirical treatment with cefepime to cover coliforms, Pseudomonas aeruginosa , and Salmonella species. Since the patient remained afebrile, hemodynamically stable, and had negative urine cultures, the ID and Urology teams decided to continue empiric antibiotics and monitor the patient rather than pursue surgical intervention. Lumbar puncture, gram stain, and a viral polymerase chain reaction (PCR) panel did not reveal any bacterial or viral source of infection.

The patient was admitted to the hospital for overnight monitoring and management. Overnight the patient’s temperature spiked to 101.7 F briefly, but he otherwise remained afebrile. The patient continued to urinate and feed without difficulty. Repeat CBC showed improvement with WBC down trending to 10.9 and neutrophils at 52.6 %. Repeat scrotal ultrasound demonstrated normal arterial and venous blood flow and decreased scrotal skin thickening. In consultation with the ID team, further history revealed that the infant’s feeding bottles had been in contact with uncooked poultry, leading to concerns about Salmonella cross-contamination. Given the patient’s change in bowel movement frequency and quality, along with the acute febrile episode, a stool PCR test was subsequently sent and returned positive for Salmonella species , leading to the likely diagnosis of Salmonella EO. Culture results noted susceptibility to ampicillin, ciprofloxacin, and trimethoprim/sulfamethoxazole. The patient was discharged the next day following continued clinical improvement of acute hemi-scrotum and confirmation of negative blood, urine, and CSF cultures following 36 hours. Cefdinir was prescribed for 3 weeks. 1-week follow-up demonstrated resolution of scrotal erythema and induration with reduced ultrasound appearance ( Figs. 3–4 ).