Editorial comment from Dr. Alonso, Dr. Perez‐Bertolez, and Dr. Castro to neonatal adrenal hemorrhage presenting as an acute scrotum: A case report on the rare presentation of right adrenal hemorrhage and contralateral left scrotal hematoma

Neonatal adrenal hemorrhage (NAH) is an infrequent condition (1.7–2.1/1000 births). ¹ It is more common in boys and on the right side (70%) as in the case reported by Okamoto et al., ² where it can be compressed between the liver and spine. It is remarkable that adrenal glands in newborns are approximately 10–20 times bigger in comparison with adults relative to body weight, increasing their vulnerability. ¹

As it is explained by these authors, ² NAH is associated with difficult delivery, shock, septicemia, coagulopathy, and any factor leading to hypoxia and redistribution of blood toward the central nervous system, heart, and adrenal gland. Spontaneous and prenatal occurrences are also documented.

Manifestations depend on the degree of hemorrhage and adrenal cortex compromised. The most frequent presentations are anemia, jaundice, abdominal distention, and flank mass. ¹ The scrotal discoloration (Bryant's sign), seen in this patient, and inguinal ecchymosis (Stabler's sign) are unusual. Nevertheless, when they are present, we should suspect retroperitoneal hemorrhage.

Hemogram, biochemistry, and coagulation tests are required. Clinical and ultrasonography (US) follow‐up is mandatory for the assessment of hemorrhage resolution and conservative management.

We think that the magnetic resonance imaging performed to this patient was not necessary after the diagnosis of NAH because it does not provide additional information. However, it may help at first to differentiate this etiology from neonatal cystic neuroblastoma.

What is noticeable about this case is the presence of NAH with contralateral scrotal hematoma, which is poorly reported. Additionally, the only risk factors were vaginal delivery, male gender, and being a term neonate.

On the other hand, scrotal hematoma often raises the suspicion of testicular torsion. Perinatal testicular torsion is unusual (6.1/100,000 births). Most of them (75%) undergoing prenatally. Physical examination reveals firm, erythematous swollen testicles that do not transmit light. US shows an enlarged testis and epididymis. ³

To conclude, we agree with the authors that NAH should be ruled out in cases of acute scrotum, mostly after a difficult delivery and/or asphyxia. A US is the first step, since it does not necessitate neither radiation nor sedation. An integration of clinical information, physical examination, and US is necessary to achieve the diagnosis. This association allows conservative treatment, avoiding a surgical exploration.

Conflict of interest

The authors declare no conflict of interest.