Atypical Cutaneous Manifestation—Scrotal Dermatitis and Epididymo-Orchitis in Two Cases with Dengue Fever

Dear Editor,

We describe two cases of dengue fever seen during an endemic outbreak, who had scrotal edema, dermatitis, and epididymo-orchitis as atypical cutaneous manifestations and discuss the typical and atypical cutaneous manifestations of dengue fever.

Case 1

A 19-year-old male admitted with complaints of fever for four days was referred to the dermatology out patient department for swelling and rash over the scrotum of three-day duration. There was no abdominal pain, dysuria, loose stools, or any prior topical applications. He was afebrile, normotensive, and vitals were stable. Local examination revealed diffuse mildly tender edema, erythema, scaling, and erosions with crusting over the scrotum [Figure 1]. Investigations revealed hemoglobin 16.0 g/dl, hematocrit 49.6%, total leucocyte count 3200/mm³, platelet count 49,000/mm³, normal renal parameters, mildly elevated liver enzymes, and positive for dengue NS1 antigen and IgM antibody. Widal test, RPR test, HIV test, and peripheral smear for malarial parasite were negative. Ultrasonography abdomen and pelvis showed normal right testis and inflammation and increased vascularity of the left testis suggesting left epididymo-orchitis. Urine microscopic and culture examinations were negative. A urology opinion was obtained and he was treated with topical emollients and systemic antibiotics for orchitis and to prevent secondary bacterial infection of scrotal erosions. The serial platelet counts gradually reached normal level and scrotal swelling and dermatitis subsided after five days and he was discharged.

Figure 1.

Diffuse edema, erythema, scaling, erosions, and crusting over the scrotum

Case 2

An 18-year-old male presented with erythematous rash, irritation, and erosions with scaling and crusting over the scrotum [Figure 2] of three-day duration. He had febrile illness one week back which had subsided in three days. He had not applied any topical applications previously. His general physical and systemic examinations were unremarkable. Investigations during the febrile illness revealed hemoglobin 13.0 g/dl, total leucocyte count 5300/mm³, platelet count 1,71,000/mm³, normal renal parameters and liver enzymes, and positive for dengue NS1 antigen and IgM antibody. Widal test, chikungunya antibody test, and peripheral smear for malarial parasite were negative. Ultrasonography was not done as there was no scrotal swelling. The patient was treated with topical emollients and systemic antibiotics due to scrotal erosions.

Figure 2.

Erosions, crusting, and scaling over the scrotum

Dengue fever is a vector-borne disease caused by dengue virus (DENV) belonging to the family Flaviviridae and transmitted by the Aedes aegypti mosquito. There are four serotypes—DEN 1 to 4 and all of them cause endemic outbreaks in India. The clinical characteristics vary from a flu-like febrile sickness to severe forms like dengue hemorrhagic fever and dengue shock syndrome.[1]

Cutaneous rash is estimated to occur in 50–80% of the patients. The initial rash at the onset of fever is a transient flushing erythema of the face because of capillary dilatation. A maculopapular or morbilliform eruption with islands of normal skin due to immune response to the virus occurs three–six days after the onset of illness. This characteristically starts from the dorsum of the hands and feet and spreads to the arms, legs, and trunk, usually sparing the palms and soles. Petechiae and ecchymoses are more frequently seen in cases of dengue hemorrhagic fever. Mucosal involvement like conjunctival congestion, hemorrhagic lip crusting, and tiny vesicles on the soft palate may occur.[2] Also, atypical cutaneous lesions like vesiculobullous lesions resembling staphylococcal scalded skin syndrome, acute scrotal edema, and epididymo-orchitis have been reported in dengue fever.[2,3,4,5]

Both the cases in our report presented with scrotal dermatitis, edema, and erosions as the only cutaneous manifestation on the third to fourth day when the febrile illness was subsiding. This timeline of the scrotal rash coincided with the usual time of onset of the commonly seen immune-mediated diffuse morbilliform rash in dengue fever. Scrotal edema in dengue fever may occur due to leakage from increased vascular permeability or as an inflammatory immune response to DENV antigen with the endothelium as the target.[3,4] The latter mechanism may explain the inflammatory scrotal swelling and dermatitis in our patients. The previously reported cases of scrotal edema in dengue fever had presented with features of acute idiopathic scrotal edema (AISE), while our cases had developed scrotal dermatitis also. AISE presents as a self-limiting edema and erythema of the scrotum and resolves without sequelae in one–three days. The specific sonographic findings for AISE include thickening and edema of the scrotal wall and hyperemia of the scrotum along with normal appearance of the testicles.[4,5] It is important to differentiate AISE from a scrotal surgical emergency like testicular torsion, incarcerated inguinal hernia, and trauma by ultrasonography to avoid unnecessary surgical exploration.

Our first patient had sonographic findings of epididymo-orchitis also. The other causes of epididymo-orchitis like Chlamydia trachomatis, Neisseria gonorrhoeae, and mumps were ruled out by history, physical examination, and negative urine microscopic and culture examination. Specific tests like NAAT or PCR could not be done due to nonavailability. But the occurrence of epididymo-orchitis during an outbreak of dengue fever, association with scrotal edema and dermatitis, and previous case reports of orchitis in dengue fever point to dengue as the cause of epididymo-orchitis in our case.[3,6] Epididymo-orchitis may be immune-mediated similar to other atypical systemic manifestations in dengue fever like hepatitis, cholecystitis, encephalitis, and myocarditis.[2] In a prospective study, Mons et al.[7] have demonstrated DENV RNA in sperm and nonsperm cells and seminal plasma, but not motile spermatozoa cell fractions. Also, they found decreased sperm production 30 days after symptom onset with no significant changes in the level of reproductive hormones and have postulated that these transient sperm alterations could have resulted from the viral infection itself, from fever, or from both. As there is a paucity in studies on the management of epididymo-orchitis in dengue fever we followed management similar to that of mumps orchitis. Treatment for mumps orchitis is supportive (bed rest, scrotal support, and the use of nonsteroidal anti-inflammatory agents) and broad-spectrum antibiotics to prevent bacterial infection of the edematous testicular tissues. Steroid administration in mumps orchitis helps in diminishing pain and edema, but it does not alter the clinical course of the disease or prevent future complications.[8] But, corticosteroids were not considered in our case due to thrombocytopenia and there is no clear evidence for the role of corticosteroids in severe dengue illness or preventing complications in the early stages of dengue.[9] Though our case recovered without complications similar to the previously reported cases, the long-term sequelae of epididymo-orchitis are not known and need to be studied.[3,6]

To conclude, atypical manifestations of dengue fever are increasingly being encountered with continuing endemic outbreaks. This case report highlights atypical cutaneous manifestations of scrotal edema, dermatitis, and epididymo-orchitis in dengue fever that were managed conservatively and resolved without complications.

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Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.