Orchitis in a 7-year-old child with coronavirus disease 2019 infection

Hossein Ali Ghaffaripour; Elham Sadati; Sara Haseli; Seyed Alireza Mahdaviani; Zahra Daneshmandi; Parisa Honarpisheh

doi:10.4103/jpdtsm.jpdtsm_92_22

CASE REPORT

Year : 2023 | Volume : 2 | Issue : 1 | Page : 67-70

Orchitis in a 7-year-old child with coronavirus disease 2019 infection

Hossein Ali Ghaffaripour¹, Elham Sadati¹, Sara Haseli², Seyed Alireza Mahdaviani³, Zahra Daneshmandi³, Parisa Honarpisheh¹
¹ Department of Pediatrics, Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Masih Daneshvari Hospital, Tehran, Iran
² Department of Radiology, Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Masih Daneshvari Hospital, Tehran, Iran
³ Department of Allergy and Immunology, Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Masih Daneshvari Hospital, Tehran, Iran

Date of Submission	20-Oct-2022
Date of Decision	09-Jan-2022
Date of Acceptance	20-Jan-2023
Date of Web Publication	13-Mar-2023

Correspondence Address:
Parisa Honarpisheh
Masih Daneshvari Hospital, Darabad Avenue, Niavaran St., ZIP: 1956944413, Tehran
Iran

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpdtsm.jpdtsm_92_22

Abstract

Although a little is known about the impact of coronavirus on male genitalia, the expression of virus receptors in this system makes it a potential target for this virus. Here, we reported orchitis as a late complication following coronavirus disease 2019 infection, which highlights the importance of follow-up in these patients.

Keywords: Coronavirus disease 2019, orchitis, scrotal discomfort

How to cite this article:
Ghaffaripour HA, Sadati E, Haseli S, Mahdaviani SA, Daneshmandi Z, Honarpisheh P. Orchitis in a 7-year-old child with coronavirus disease 2019 infection. J Prev Diagn Treat Strategies Med 2023;2:67-70

How to cite this URL:
Ghaffaripour HA, Sadati E, Haseli S, Mahdaviani SA, Daneshmandi Z, Honarpisheh P. Orchitis in a 7-year-old child with coronavirus disease 2019 infection. J Prev Diagn Treat Strategies Med [serial online] 2023 [cited 2023 Mar 31];2:67-70. Available from: http://www.jpdtsm.com/text.asp?2023/2/1/67/371636

Introduction

The coronavirus disease 2019 (COVID-19) is still spreading worldwide and infecting all age groups. Initially, a fewer children were affected; therefore, many features of this disease, especially atypical manifestations, have not yet been identified in this population, and further time is needed to clarify it.^[1] Developed symptoms have changed over time, and the emergence of new strains and virus mutations contribute to these changes.^[2] COVID-19 in children is most often asymptomatic.^[3] Symptomatic children present primarily with fever, upper and lower respiratory airway manifestations, gastrointestinal symptoms, and Kawasaki-like symptoms.^[4] Genitalia complaints seem to be rare in COVID-19 patients, especially in children, and there are a few reports of scrotal discomfort.^[5] Here, we report a case of orchitis in a 7-year-old boy in the third week of the disease. Orchitis was diagnosed based on the clinical and radiological investigations and recovered spontaneously with a supportive care.

Case Report

A 7-year-old boy was admitted to our outpatient clinic with a history of fever, myalgia, diarrhea, vomiting, and nonproductive cough. The fever ceased after 4 days, but the cough continued. The oxygen saturation was 96%. On physical examination, he had expiratory wheezing without tachypnea. The nasopharyngeal swab polymerase chain reaction test for COVID-19 was positive. He had a history of asthma that was well controlled. Biochemical and hematologic tests showed lymphopenia (white blood cell: 3400/μL with 26% lymphocytes) and a mild increase in aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and D-dimer (AST: 65 [NL: <40 IU/L], LDH: 540 [NL: <170 units/L], D-dimer: 800 [NL: <500 ng/ml]). Urine analysis and urine culture were normal. The chest X-ray showed only hyperaeration. The child underwent outpatient treatment with montelukast 5 mg daily, one puff Symbicort inhaler 160 mcg twice a day, and acetaminophen. At the follow-up visit, the patient's symptoms resolved after 5 days, but erythematous itchy lesions on the palmar and plantar surfaces appeared, which resolved spontaneously. In the 3^rd week of the disease, the child was admitted to the emergency department with swelling, pain, and erythema in the right testicles [Figure 1].

Figure 1: Testicle involvement after coronavirus infection: erythema and mild swelling in the right testis (arrow)

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Testicular pain presented with a gradual onset and accelerated during the next days and woke up the child. The patient had no history of recent trauma. The right testis was erythematous and tender and was located in the normal position on physical examination. There was no significant groin lymphadenopathy, and bilateral cremasteric reflexes were intact. Regarding severe scrotal pain to rule out torsion of the testis or testicular appendage, a color Doppler ultrasound (DUS) was performed, which showed thickening and edema of the right scrotal wall and diffuse hypervascularity and hyperemia of the right testicle, all of which are suggestive of orchitis [Figure 2].

Figure 2: Color Doppler of the testis: Longitudinal Doppler ultrasound of the right testis demonstrates edema and thickening of the scrotal wall as well as increased testicular vascularity and extensive hyperemia of the right testicle on color Doppler which all are compatible with orchitis

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The patient was diagnosed with orchitis associated with COVID-19 and underwent conservative treatment, including a reduction in physical activity, ibuprofen syrup 200 mg every 8 h, and scrotal elevation for 3–4 days. On the 5^th day, erythema and swelling subsided on scrotal examination and completely resolved approximately 2 weeks later. No further imaging was conducted given his clinical improvement.

Discussion

Although coronavirus mainly affects the lungs, many other organs are involved in the disease.^[6] Several factors have been involved in the development of COVID-19 infection; entry of SARS-COV-2 into the target cells is a significant determinant of coronavirus infection. Coronavirus first binds to angiotensin-converting enzyme 2 (ACE2) as a cell surface receptor, and after viral attachment, cell surface protease activators such as transmembrane serine protease SS2 (TMPRSS2) activate coronavirus entry.^[7],[8] ACE2 and TMPRSS2 are expressed in various tissues, including the male urogenital, making it vulnerable to SARS-COV-2 infection.^[9] ACE2 is present in almost all testis cells, especially the Sertoli cells ^{More Details}. Liu et al., through single-cell transcriptome analysis of male germ cells, reported ACE2 expression in male testis,^[10] which reflects that the genital system is regarded as at risk for this virus and may be a potential target for this virus.

To date, there are a few reports about male genitalia involvement in the setting of COVID-19, and only a few cases of them have been reported in children that mainly have been associated with multisystem inflammatory syndrome in children (MIS-C); the first case of epididymo-orchitis associated with COVID-19 was reported in a 14-year-old boy in Italy.^[11] After that, Haydar et al. reported a case of epididymitis in the setting of MIS-C in a 7-year-old boy from Syria.^[1] Subsequently, two other cases of epididymo-orchitis with MIS-C were reported.^[12] In a systematic review conducted on 575 patients, including 538 males, scrotal discomfort, swelling, pain, and erythema were described in 39 patients, among whom acute orchitis was found in 10 patients and acute orchiepididymitis in 10 patients.^[5] Other reported cases of genitourinary complications of SARS-COV-2 were mainly among adults^{[13],[14],[15],[16]} [Table 1].

Table 1: Genitourinary complications of SARS-CoV-2

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Scrotal pain is a diagnostic challenge in children that necessitates an accurate evaluation. The most common causes of acute scrotal pain in children include testicular torsion, appendix testis torsion, orchitis, and epididymitis. The most important reason for scrotal discomfort is testicular torsion, a surgical emergency that requires an immediate diagnosis and treatment.^[17] DUS is the choice modality for ruling out scrotal torsion from other causes of scrotal discomfort and determining the presence of blood flow.^[18]

Orchitis is a local inflammation associated with the abrupt onset of testicular pain and swollen and tender testicles in examination findings and hypoechoic and hypervascular areas in ultrasound. The cremasteric reflex is intact, and the testis is in its normal anatomic location. Orchitis in children usually occurs secondary to viral infections, most commonly mumps virus. Less commonly, it is caused by bacterial organisms, and in these conditions, orchitis occurs as a result of the spreading of infection from epididymitis. Some cases of orchitis also have been reported following COVID-19 infection and it seems this virus is also another cause of viral orchitis. Therefore, this complication should be considered in patients with COVID-19 and in any patient with orchitis of unknown cause to recognize this complication in the early stage of the disease and prevent subsequent awful outcomes. The treatment of orchitis depends on the underlying cause, and in viral cases, supportive treatments such as analgesics, bed rest, hot or ice packs, and scrotal elevation are used, and symptoms will go away on their own.^[19]

Conclusion

This case and a few reported cases of orchitis following COVID-19 indicate that the male genital system may be a target organ for the virus, and COVID-19-related orchitis, although rare, should be considered in the differential diagnosis of testicular pain in COVID-19 patients. The expression of coronavirus receptors in this organ can be regarded as a target for virus invasion and is probably an important determinant of viral infectivity. Cytokine release and subsequent inflammation can occur in the testes tissue and induce orchitis, but further study should be conducted to investigate the pathogenesis.

Declaration of patient consent

The authors certify that they have obtained written informed consent from the parents of the child to publish images and other clinical information about their child in accordance with the journal's patient consent policy.

Acknowledgment

The authors of this article would like to express special thanks to the patient for consent to publish his images and clinical history.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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