Blue Scrotum – A Sign of Neonatal Adrenal Hemorrhage

A male newborn was delivered through vacuum extraction – at 40 weeks gestation. At birth, he required positive pressure ventilation for one minute due to hypotonia and bradycardia. He quickly regained normal breathing, heart rate, and muscle tone. His Apgar scores were 6 and 8 at 1 and 5 minutes, respectively. 

Umbilical cord blood gas analysis showed mixed respiratory and metabolic acidosis (pH < 7, pCO2 99 mm Hg, lactate 7.4 mmol/L, base excess 12 mmol/L). Despite the challenging delivery, his physical examination shortly after birth was normal.

Two days later, the infant developed a bluish discoloration and painless swelling of the right hemiscrotum (Bryant’s sign) – indicating neonatal adrenal hemorrhage. 

This diagnosis was confirmed through abdominal ultrasonography. Blood tests, including electrolytes, chemistry, prothrombin time, and activated partial thromboplastin time, were all normal. 

No treatment was necessary, and follow-up examinations, both clinical and ultrasonographic, showed complete resolution after four weeks.

Scrotal ecchymosis can result from various conditions, including testicular torsion, orchitis, hydrocele, complicated inguinal hernia, meconium peritonitis, hematocele, traumatic hematoma, congenital tumors, or neuroblastoma. In such cases, symptoms such as pain, irritability, and poor feeding are typically present, along with swollen and erythematous testes. In contrast, scrotal ecchymosis from retroperitoneal bleeding, like in neonatal adrenal hemorrhage, is painless and associated with an otherwise normal scrotal examination.

Neonatal adrenal hemorrhage, often involving the right adrenal gland, can cause bluish discoloration of the scrotum due to blood spreading from the adrenal gland into the retroperitoneum or peritoneal cavity. Although the condition is usually asymptomatic and resolves without intervention, severe cases can lead to significant complications, such as bleeding or adrenal insufficiency, which may require surgical intervention.

Source: Puzone S, Montaldo P. The Journal of Pediatrics. 2024 Nov 1;274.