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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 29  |  Issue : 2  |  Page : 328-330

Penoscrotal angioedema in an 8-year-old boy following insect bites


1 Department of Surgery, Division of Urology, Edo University, Iyamho, Nigeria
2 Department of Surgery, Division of Paediatric Surgery, Edo University, Iyamho, Nigeria

Date of Submission15-Jan-2020
Date of Decision13-Mar-2020
Date of Acceptance21-Apr-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Dr. Friday Emeakpor Ogbetere
Department of Surgery, Division of Urology, Edo University, Iyamho
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_52_20

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  Abstract 


Angioedema in children displays a varied etiology and clinical manifestations, unlike adult angioedema. As opposed to angioedema in adults, pediatric angioedema majorly results from food, insect bites, and drugs. Reactions to insect bites, both allergic and toxic, are frequently encountered in pediatric medical practice but rarely seen in urological practice. Here, we present a case of penoscrotal angioedema resulting from an insect bite in the affected region. This case report emphasizes the need to consider penoscrotal angioedema as an important differential diagnosis of genital swelling, as early diagnosis may obviate fatal complications.

Keywords: Allergy, angioedema, giant urticaria, penoscrotal swelling


How to cite this article:
Ogbetere FE, Akerele WO. Penoscrotal angioedema in an 8-year-old boy following insect bites. Niger J Med 2020;29:328-30

How to cite this URL:
Ogbetere FE, Akerele WO. Penoscrotal angioedema in an 8-year-old boy following insect bites. Niger J Med [serial online] 2020 [cited 2020 Sep 20];29:328-30. Available from: http://www.njmonline.org/text.asp?2020/29/2/328/287929




  Introduction Top


Angioedema is the rapid swelling of the area beneath the skin or mucosa occurring in both hereditary and nonhereditary forms. It is anatomically limited and nonpitting. It seems to be closely linked with general urticaria. Angioedema denotes similar but larger swellings of the deep dermal, subcutaneous, and submucosal tissues.[1] It is known by various names such as giant urticaria and angioneurotic edema.[2] Angioneurotic edema may be fatal, particularly with systemic involvement.[3]

Although reactions to insect bites are commonly seen in general medical practice,[4] angioneurotic edema is not often seen in urological practice. Penoscrotal angioedema is rarely considered as a differential diagnosis of scrotal or penoscrotal swelling, particularly in the pediatric age group. Herein, we present an 8-year-old boy with genital angioedema in whom the pathology appeared to result from a centipede sting on his scrotum with subsequent swelling of his penis and scrotum.


  Case Report Top


Master CP was an 8-year-old boy who was brought to the urology clinic by the mother with a day history of penoscrotal swelling, scrotal skin rash, and pruritus. A day before the onset of these symptoms, he was said to have been stung on the scrotum by a centipede on the bed he slept on. This was identified and killed. Following this, he complained of scrotal pain which subsided within 2 h. The following morning, he developed progressive scrotal swelling and subsequently penile swelling. He was also noticed to have the pruritic rash about the same time. There was no prior history of penile or scrotal swelling. He had no family history of such ailment. This was the first episode of genital swelling. No sore was present on the penis or scrotum. There was neither urethral discharge nor lower urinary tract symptoms.

Examination revealed a distorted, grossly edematous penis and a diffuse, soft, nonpitting edematous scrotum with papular skin rash involving the dorsal aspect of the scrotum [Figure 1]. Both penis and scrotum were nontender. There was no inguinal lymphadenopathy or erythema, and the remainder of the genital examinations were unremarkable. He was not dyspneic and had a respiratory rate of 20/min. His pulses were of normal volume, and his heart rate and blood pressure were 92/min and 90/50 mmHg, respectively. The heart sounds were normal. He did not have any other significant abnormalities in other systems. Investigations done included urinalysis and full blood count. All these were within normal ranges.
Figure 1: Penoscrotal edema following insect bite

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A diagnosis of angioneurotic edema was made. He was subsequently placed on a tapered dose of steroid and antihistamine for 5 days. All symptoms resolved without complications within 4 days [Figure 2] and had not recurred at follow-up 2 months later.
Figure 2: Resolved penoscrotal swelling after 4-day treatment

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  Discussion Top


Angioedema is a variant of urticaria resulting from extravasation of fluid into the subcutaneous tissue.[5] Skin lesions may be seen on the lips, eyelids, tongue, pharynx, and the genitalia. Sudden onset is typical, and skin changes last for some hours to a few days.[6] While the majority of cases are acquired, hereditary angioedema accounts for 5% of cases of angioedema.[7]

The incidence of angioedema is the same for both males and females and peaks in the third and fourth decades of life,[8] which said that angioedema in children exhibits a varied cause, severity, and clinical manifestation than in the adult. On the whole, acute attacks are more frequent in children and are often as a result of allergic reactions or infection.[6],[7]

Probable causes of angioedema are food (40%), insect bites (30%), infection (20%), and antibiotics (10%).[6],[8] In addition, there are reported cases of genital edema triggered by trauma to the perineum, horse riding, or following sexual intercourse.[6] There have also been reported cases without a trigger factor.[7] The angioedema of our patient was from a centipede bite.

Reactions to insect stings are seen regularly in pediatric clinical practice.[9] Characteristic reactions following an insect sting are erythema, itching, pain, swelling, and indurations limited to the area of the sting. Large local reactions also occur commonly involving large areas of the skin typically with sometimes swelling as large as 10 cm in diameter around the location of the bite. These swellings generally peak within 2 days, but reactions can persist for up to 7–10 days. Children exhibit predominantly facial (80%) and lip (40%) edema.[4] When the external genitals are involved, it may present a diagnostic dilemma as genital angioedema is relatively rare and not often considered as a cause of genital swelling. Although systemic reactions to insect bites are <1% in children, they can be life-threatening.[4]

Understanding the different possible etiology is the preliminary step in managing angioedema. For allergic angioedema, the first line of action is to remove the cause and clean and rinse the area and then addresses the systemic manifestation.[6] The initial management of systemic reactions targets the treatment of anaphylaxis, for which administration of epinephrine (0.3 ml of a 1/1000 dilution) is the favored treatment. This is essentially employed in the emergency treatment of nonhereditary angioedema involving larynx. It can be administered intramuscular and subcutaneous routes or inhaled when the reaction is severe.[4]

An antihistamine, such as diphenhydramine or hydroxyzine, may be administered to reduce pruritus and inflammation.[4] When the conventional H1 and H2 antihistamine failed, other second-line drugs such as nifedipine may be used as an adjunct. Some authors believe in the use of systemic steroid as the mainstay of treatment. Topical steroids also have been noted to be useful.[9] Our patient had resolution of symptoms following administration of a tapered dose of dexamethasone and diphenhydramine for 4 days. Intravenous fluids for volume expansion and enhanced diuresis or ventilator support for management of lung edema is a useful supportive care.[5]


  Conclusion Top


Angioedema should be considered as a differential diagnosis of genital swelling of acute onset in children. Patients who have no evidence of urinary retention from complications such as phimosis and paraphimosis can be safely discharged on a dose of oral steroids and antihistamines and instructed to discontinue the offending agent and to return in case of development of the aforementioned conditions.

Declaration of consent

The authors have obtained all necessary consent from the patient's mother. They have also been informed that his identity will not be revealed in any way.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaplan AP, Adkinson NF Jr. Middleton's Allergy: Principle and Practice. 7th ed. Philadelphia: Mosby, Urticaria and Angioedema. 2009. p. 1061-81.  Back to cited text no. 1
    
2.
Deutsch ES, Zalzal GH. Quinke's oedema, revisited. Arch Otolaryngol Head Neck Surg 1991;117:100-2.  Back to cited text no. 2
    
3.
Ulmer JL, Garvey MJ. Fatal angioedema associated with lisinopril. Ann Pharmacother 1992;26:1245-6.  Back to cited text no. 3
    
4.
Booker GM, Adam HM. Insect stings. Pediatr Rev 2005;26:388-9.  Back to cited text no. 4
    
5.
Greaves MW, Lawlor F. Angioedema: Manifestations and management. J Am Acad Dermatol 1991;25:155-61.  Back to cited text no. 5
    
6.
Warner JO. Anaphylaxis; the latest allergy epidemic. Pediatr Allergy Immunol 2007;18:1-2.  Back to cited text no. 6
    
7.
McCabe J, Stork C, Malloux D, Su M. Penile angioedema associated with the use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers. Am J Health Sys Pharm 2008;65:420-1.  Back to cited text no. 7
    
8.
Cunningham DS, Jensen JT. Hereditary angioneurotic oedema in the puerperium: A case report. J Reprod Med 1991;36:312-3.  Back to cited text no. 8
    
9.
Chaitra TR, Ravishankar TL, Nalawade TM. Angioneurotic oedema: Report of two cases. Braz J Sci 2012;11:505-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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