Case Presentation: A 34 year old man with no known medical illnesses presented with a three-day history of progressively worsening acute-onset left inguinal swelling. The swelling was associated with a pain severity score of 10/10. He denied any nausea, vomiting, diarrhea, constipation, abdominal pain or decreased/absent flatus. Social history was significant for alcohol use and binge drinking on weekends. On arrival to the ED, vitals were BP 104/74 mmHg, T 98.7F and P 124 bpm. On exam, the patient had no abdominal tenderness or masses however had a swelling to the left groin extending to the left scrotal sac. The swelling was firm to palpation, tender and partially reducible with a positive cremaster reflex. Blood work was significant for WBC 36.4 K/Ul with bandemia of 32% , sodium to 122 mmol/L, AST 227 U/L/ALT 286 U/L, alkaline phosphatase 202 U/L and lipase 1,055 U/L. Urinalysis had 2+ blood, WBC 3 with no nitrites and urine culture was negative. CT abdomen showed features of acute pancreatitis with an occlusive thrombus in the right segmental level portal vein and non-occlusive thrombus in the main portal vein extending into the superior mesenteric vein. Fluid was seen tracking into the left paracolic gutter along the left leg wall and through a patent processus vaginalis into the left hemiscrotum. Scrotal ultrasound with duplex showed a diffusely enlarged heterogeneous left epididymis suspicious for epididymitis. Chlamydia and gonococcal PCR were negative. Our patient was diagnosed as having sepsis likely secondary to pancreatitis. Treatment course included antibiotics, imipenem/cilastin which was switched to levofloxacin on discharge and a heparin infusion which was eventually switched to apixaban on discharge.
Discussion: Unilateral scrotal swelling as the presenting symptom for pancreatitis was first reported in 1979 and has since only been seen sporadically in case reports. In the case of our patient, he was incidentally found to have mild acute pancreatitis per Modified Atlantic criteria as he had features of pancreatitis found on CT imaging with an elevated lipase in the absence of abdominal pain and local infection. The scrotal swelling seen was a result of the pancreatic fluid draining via the pericolic gutter to the patent processus vaginalis. The treatment of pancreatitis with associated scrotal swelling remains the same; however if the swelling does not improve there is the option of drainage of the scrotal collection to prevent persistent sepsis (1). Our patient clinically improved by day two of antibiotics and did not require any further intervention.
Conclusions: Despite the unusual presentation of scrotal swelling in pancreatitis, this symptom in itself does not change the overall management of the disease. (2) However, it does highlight that one should be vigilant for acute pancreatitis in high-risk individuals where scrotal swelling is the only presenting symptom.