PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s visual diagnosis competition. It is held annually at the National Conference and Exhibition. This year, all ten finalists will be posted online on PEMBlog.com and at PEMPix.com, one a day with voting opening to AAP Section on Emergency Medicine members thereafter. I hope you enjoy this online-only format, and hope that it will serve to highlight some of the fantastic learning cases that our colleagues submitted this year. It was again very difficult for the panel of judges to select the finalists and I could not have done it without their assistance. As a special treat I’ve included a musical selection form the 1980s as an optional “hint,” and to serve as a soundtrack for your learning.

This PEMPix case was submitted by:

Yae Sul (Hazel) Jeong, MD, Pediatric Emergency Medicine Fellow along with Dan Ngyuen, MD and Vito Rocco, MD from William Beaumont Hospital in Royal Oak, Michigan

Click here to reveal the hint

That’s not supposed to be there

A previously well 16 year old male with a past medical history of ASD and pulmonary valve stenosis (on enalapril), along with well controlled epilepsy (on oxcarbazepine) presents with whitish discharge from his left lateral side of scrotum when he was straining to make a bowel movement. This is the first time it happened and it freaked him out. He vociferously denies trauma, pain, redness, fever, or swelling. Additionally he is not sexually active and has no discharge, hesitancy, urgency or other urinary symptoms. He is not constipated.

In addition to stable cardiac and epilepsy history he also underwent cranioplasty as a toddler for premature fusion of the cranial sutures. His mother recalls that he had a varicocele earlier in adolescence as well.

His physical exam is unremarkable aside from the following genitourinary findings.

Uncircumcised male with a small amount of smegma around the glans
The testes are normal
No overlying erythema, warmth, fluctuant or tenderness of the scrotum
No hernia, hydrocele, or varicocele
Cremaster reflex is present
There is a thick whitish discharge emanating from the upper left side of the scrotum
Mild left inguinal lymphadenopathy

An ultrasound was performed and revealed a left epididymal cyst without evidence of testicular torsion. There was also a small bilateral varicocele. The fluid gram stain was negative for organisms. The fluid triglycerides were 1,941 ng/mL (normal range 0-64 mg/dL).

What is the diagnosis?

A. Ruptured inguinal bubo

B. Scrotal cutaneous chylous reflux

C. Ruptured testicle cyst

D. Filariasis

E. Scrotal abscess

Click here to reveal the correct answer

B. Scrotal cutaneous chylous reflux

This is a rare condition with only a few cases reported in the literature. It is the result of fluid reflux from the inguinal lymphatic system into the scrotum. Primary chylous reflux is an idiopathic etiology. Secondary chylous reflux can be due to previous irradiation, malignancy, surgery, trauma, or filariasis. Ultrasound will evaluate scrotal contents but not make the diagnosis. CT, MRI, and really, lymphography can show the presence of reflux from the inguinal lymphatics into the scrotum.

Diagnosis of chylous fluid is confirmed by ≥2 of the following:

Appearance of milky fluid
Triglyceride level >1 – 24 mmol/L
lipoprotein analysis for the presence of chylomicrons

The goal of therapy is to reduce the chylous reflux. and most cases can be managed conservatively with a low-fat diet, diuretics, antibiotics, and compression garments. A selected few will require resection of the retroperitoneal and mesenteric lymphatics with or without sclerotherapy. In this case a hypertonic saline compressive dressing was beneficial early on.

Inguinal buboes are localized enlargements in the groin area which are painful & may be fluctuant. They are frequently associated with lymphogranuloma venereum.

A ruptured trichilemmal testical cyst is a sebaceous cysts that is usually filled with clear fluid but may become infected and leak discharge pus. Ultrasound will show a well circumscribed round hypoechoic lesion with no internal blood flow.

Scrotal chylorrhea is a rare complication of filariasis, a helminthic infection that can involve the lymphatic system. Patients usually present with lymphedema, and limb swelling related to chronic inflammation of the lymphatic vessels. This was not the case for the patient, who also did not reside in an endemic area.

Scrotal abscesses will present with erythema, swelling, fluctuance and tenderness. This patient only had drainage. A scrotal pyocele is a complication of epididymo-orchitis or testicular abscess. The purulent fluid collection generally arises from communication between the infected testicle or testicular abscess and an existing hydrocele, through the mesothelial lining of the tunica vaginalis.