李蕎青^1,2、劉沁瑜³、查岱龍¹、孫光煥¹、于大雄¹、吳勝堂¹、曹智惟¹

¹三軍總醫院外科部泌尿外科；²國軍高雄總醫院外科部；³輔仁大學營養科學系

Chiao-Ching, Li^1,2、Chin-Yu, Liu³、Tai-Lung, Cha¹、Guang-Huan, Sun¹、Dah-Shyong, Yu¹、

Sheng-Tang, Wu¹、Chih-Wei, Tsao¹

¹Division of Urology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan；²Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan；³Department of Nutritional Science, Fu Jen Catholic University, New Taipei, Taiwan

 

The 89-year-old man had suprapubic tube cystostomy since 1 year ago because of bulbous urethral stricture. Besides, he had past history of perforated gastric ulcer status post subtotal gastrectomy, myelodysplastic syndrome and valvular heart disease with congestive heart failure. This time, he complained painful swelling from right inguinal region to right hemiscrotum for 3 days. The stable vital signs(BT：36.7℃、HR：84bpm、RR：19cpm、BP：146/61mmHg) were manifested at emergency room. In addition, the patient stated poor appetite and no defecation for 2 days. Under physical examination, the local tenderness without local heat nor erythematous change over right inguinal region to right hemiscrotum was found as well as unreducible lump. Soft abdomen, decreased bowel sound, and no diffuse tenderness were checked. Digital rectal examination was unremarkable. The findings in blood sample were WBC：13280/uL (Neutrophil/Lymphocyte：83.9%/9.8%)、Hb：11g/dL、Cr：1.6mg/dL、Na：141mmol/L、K：3.8mmol/L、Glucose：99mg/dL、CRP：9.8mg/dL). The ultrasonography of scrotum(Figure A and B) was arranged, right side inguinal hernia with bowel loop herniation was suspected. Therefore, computed tomography scan without contrast of abdomen and pelvis(Figure C and D) was performed for further evaluation, ill-defined mass-like lesion in right inguinal region to right hemiscrotum with traction of the omentum was revealed. The differential diagnosis includes incarcerated hernia or abscess.

 Antibiotic treatment with Ceftriaxone 2G was prescribed first. Due to suspicion of incarcerated hernia, surgery was carried out. We used inguinal approach and the operative finding was not incarcerated hernia, otherwise there was spermatic cord abscess with turbid, tea-color discharge. Orchiectomy was done and 2 drainages were placed at right inguinal region and hemiscrotum. The pathology report showed necrotizing inflammation from right spermatic cord to right testis and no malignancy. The multiple drug resistant(Resistant to Cefazolin、Ampicillin、Ceftazidime、Ceftriazone、Cefepime；Susceptible to Levofloxacin、Imipenem、Doripenem、Colistin) Klebsiella pneumoniae was cultivated in pus culture. Intravenous Meropenem was used then and it was shifted to oral Levofloxacin while discharge. The patient got recovery from the surgery and was discharged after 9 days.