Blue Scrotum as a Sign of Neonatal Adrenal Hemorrhage

A male newborn was delivered by vacuum extraction at 40 weeks' gestation. At birth he required positive pressure ventilation for a minute because of hypotonia and bradycardia, with a rapid restoration of spontaneous breathing, normal heart rate, and normal tone. Apgar scores were 6 and 8 at 1 and 5 minutes, respectively. Umbilical cord blood gas analysis revealed mixed respiratory and metabolic acidosis (pH < 7, pCO2 99 mm Hg, lactate 7.4 mmol/L, base excess: −12 mmol/L). Physical examination soon after birth was normal despite the difficult delivery. Two days after birth, a bluish discoloration and painless swelling of right hemiscrotum was noted (Figure A ). This finding (Bryant's sign) suggested a neonatal adrenal hemorrhage, which was later confirmed by ultrasonography of the abdomen (Figure B). Blood electrolytes and chemistry, prothrombin time, and activated partial thromboplastin time were normal. No treatment was administered. Clinical and ultrasonographic follow-up examinations showed complete resolution after 4 weeks. Differential diagnosis for scrotal ecchymosis includes torsion of the testes, orchitis, hydrocele, complicated inguinal hernia, meconium peritonitis, hematocele, traumatic hematoma, congenital tumors, or neuroblastoma.1Avolio L. Fusillo M. Ferrari G. Chiara A. Bragheri R. Neonatal adrenal hemorrhage manifesting as acute scrotum: timely diagnosis prevents unnecessary surgery.Urology. 2002; 59: 601Abstract Full Text Full Text PDF PubMed Google Scholar, 2Lai L.J. Chen L.M. Chu P.Y. Tseng M.H. Chang C.C. Lu C.W. Neonatal adrenal hemorrhage associated with scrotal hematoma: an unusual case report and literature review.Pediatr Neonatol. 2012; 53: 210-212Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 3Raveenthiran V. Cenita S. Viswanathan P. Stabler's sign revisited in a spontaneously ruptured neuroblastoma of the newborn.Am J Perinatol. 2008; 25: 17-20Crossref PubMed Scopus (7) Google Scholar, 4Garofalo S. Guanà R. Scottoni F. Cortese M.G. Pane A. Cerrina A. et al.Newborn with supraumbilical and scrotal bruising.Ann Emerg Med. 2020; 76: e127-e128Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar However, in conditions intrinsic to the scrotum, clinical evaluation will usually reveal symptoms such as pain, irritability and poor feeding. In addition, the testes may appear swollen and erythematous.2Lai L.J. Chen L.M. Chu P.Y. Tseng M.H. Chang C.C. Lu C.W. Neonatal adrenal hemorrhage associated with scrotal hematoma: an unusual case report and literature review.Pediatr Neonatol. 2012; 53: 210-212Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,5Guida E. Del Rizzo I. Galdo F. Murru F.M. Schleef J. Risso F.M. et al.Neonatal acute scrotum: do not forget Amyand hernia.World J Pediatr Surg. 2020; 3e000139Crossref PubMed Scopus (6) Google Scholar Scrotal ecchymosis from retroperitoneal bleeding is instead painless and associated with an otherwise normal scrotal physical exam.6Giangiacomo J. Inguinal and scrotal ecchymosis as a complication of renal biopsy.J Urol. 1977; 118: 319Crossref PubMed Scopus (1) Google Scholar Accurate medical history, physical exam, and laboratory studies as well as ultrasonography are crucial to avoid unnecessary surgical exploration.1Avolio L. Fusillo M. Ferrari G. Chiara A. Bragheri R. Neonatal adrenal hemorrhage manifesting as acute scrotum: timely diagnosis prevents unnecessary surgery.Urology. 2002; 59: 601Abstract Full Text Full Text PDF PubMed Google Scholar,2Lai L.J. Chen L.M. Chu P.Y. Tseng M.H. Chang C.C. Lu C.W. Neonatal adrenal hemorrhage associated with scrotal hematoma: an unusual case report and literature review.Pediatr Neonatol. 2012; 53: 210-212Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,7Okamoto T. Kajiwara S. Sekito S. Shibahara T. Onishi T. Neonatal adrenal hemorrhage presenting as an acute scrotum: a case report on the rare presentation of right adrenal hemorrhage and contralateral left scrotal hematoma.IJU Case Rep. 2022; 5: 427-430Crossref PubMed Scopus (2) Google Scholar Bluish discoloration of the scrotum (Bryant's sign) and perineal areas (Stabler's sign) from ecchymosis are rare manifestations of neonatal adrenal hemorrhage. In 70% of cases the right adrenal gland is involved,7Okamoto T. Kajiwara S. Sekito S. Shibahara T. Onishi T. Neonatal adrenal hemorrhage presenting as an acute scrotum: a case report on the rare presentation of right adrenal hemorrhage and contralateral left scrotal hematoma.IJU Case Rep. 2022; 5: 427-430Crossref PubMed Scopus (2) Google Scholar due to its location between the liver and the spine. In addition, the venous drainage of the right adrenal gland is directly into the inferior vena cava with a greater exposition at the central venous pressure changes. Adrenal hemorrhage is typically contained within the capsule of the adrenal gland. However, blood can sometimes spread into the retroperitoneum or the peritoneal cavity and cause bluish discoloration and swelling of the scrotum. In most cases, neonatal adrenal hemorrhage is asymptomatic. Nevertheless, clinical manifestations can be variable and depend on the degree of hemorrhage. Symptoms may include palpable abdominal mass, vomiting, anemia, and jaundice. Risk factors for neonatal adrenal hemorrhage include perinatal asphyxia, difficult or traumatic delivery, large for gestational age weight, sepsis, coagulation disorders, thrombocytopenia, thrombosis of the renal vein, respiratory failure, and circulatory failure.2Lai L.J. Chen L.M. Chu P.Y. Tseng M.H. Chang C.C. Lu C.W. Neonatal adrenal hemorrhage associated with scrotal hematoma: an unusual case report and literature review.Pediatr Neonatol. 2012; 53: 210-212Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar In most cases, adrenal hemorrhage resolves spontaneously and requires no intervention.2Lai L.J. Chen L.M. Chu P.Y. Tseng M.H. Chang C.C. Lu C.W. Neonatal adrenal hemorrhage associated with scrotal hematoma: an unusual case report and literature review.Pediatr Neonatol. 2012; 53: 210-212Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar However, large neonatal adrenal hemorrhage may lead to death by bleeding or adrenal insufficiency and can require drainage or surgical exploration.2Lai L.J. Chen L.M. Chu P.Y. Tseng M.H. Chang C.C. Lu C.W. Neonatal adrenal hemorrhage associated with scrotal hematoma: an unusual case report and literature review.Pediatr Neonatol. 2012; 53: 210-212Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Simona Puzone: Writing – original draft, Visualization, Validation, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Paolo Montaldo: Writing – review & editing, Validation, Supervision, Formal analysis. The authors declare no conflicts of interest.