ILLUSTRATIVE CASE
Painless Pediatric Priapism and Cough Micah Jacobs, MD,* Mark D. Lo, MD, MS,†‡ and Thomas S. Lendvay, MD, FACS§∥ Abstract: Pediatric priapism can be a medical emergency but is not a common complaint seen in pediatric emergency department. Priapism in a previously healthy child is also rare. We report a case of painless stuttering priapism associated with an acute Mycoplasma pneumoniae infection in a previously healthy boy. Key Words: stuttering priapism, Mycoplasma pneumoniae, urologic emergency
P
riapism is an uncommon presenting complaint in pediatric emergency department and is rarely seen in previously healthy children. The most common etiologies for priapism in children include complications from sickle cell disease, trauma, oncologic sequelae, or medication use. Priapism has been twice described in previous literature in association with Mycoplasma pneumoniae infection.1,2 We present a 10-year-old child who presented with stuttering priapism of unknown etiology, which was ultimately associated with M pneumoniae.
CASE A 10-year-old previously healthy boy presented to the pediatric emergency department of an academic medical center with a complaint of approximately 5 hours of intermittent painless priapism. He had no previous medical issues and he first noted penile edema of the distal shaft that morning without complete engorgement of the corporal bodies. He then had a progressive tumescence of his phallus during the morning. He was able to urinate without difficulty or pain but developed an erection soon after urination that did not resolve. Because of the persistence of his penile swelling and erection, he sought medical care at an outside hospital emergency room. He was subsequently transferred to our pediatric emergency department to receive pediatric subspecialty care secondary to the diagnosis of priapism. The patient denied dysuria, hematuria, penile discharge, penile trauma, or masturbation. He had minimal pain despite his prolonged erection. He noted that his erection was intermittent. At the time of presentation to our pediatric emergency department, he was afebrile but reported a brief fever that had occurred 1 week before presentation. He also reported a cough and upper respiratory symptoms for 1 week before presentation. His previous medical history was not significant for chronic disease. Specifically, he did not have a history of clotting disorders, oncologic processes, medication usage, or sickle cell disease. The patient's twin brother was noted to have had an episode of idiopathic thrombocytopenic purpura in the past from which he fully recovered. There were several sick contacts at home that had recently recovered from upper respiratory illnesses. From the *Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; †Department of Pediatrics, University of Washington; ‡Division of Pediatric Emergency Medicine, Seattle Children's Hospital; §Department of Urology, University of Washington; and ∥Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA. Disclosure: The authors declare no conflict of interest. Reprints: Mark D. Lo, MD, MS, Seattle Children's Hospital, 4800 Sand Point Way NE, M/S B-5513, Seattle, WA 98105 (e‐mail: [email protected]). Copyright © 2015 by Lippincott Williams & Wilkins ISSN: 0749-5161
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On physical examination, the patient was afebrile with a blood pressure of 105/60, a heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and an oxygen saturation of 96% on room air. The patient had a Tanner stage II with a circumcised penis that was semierect (Fig. 1). Testicular examination revealed descended testes with intact cremasteric reflex bilaterally. His scrotum was nontender with no discoloration of the skin. During the course of the physical examination, his penis became fully erect and did not return to a flaccid state. A ring of subcoronal swelling was present, which the patient confirmed had been present since that morning. He had a dry cough during his examination. The pediatric urology consult service noted that his respiratory examination was significant for crackles on the right on auscultation. He had no respiratory distress at time of examination. Initial laboratory workup in the emergency department included a complete blood cell count, which was significant only for a mildly elevated white blood cell count of 12,300 with 69% neutrophils. A basic metabolic panel was within normal limits. His urinalysis showed no red or white blood cells and was nitrite negative. Of note, his blood was noted to be “thick” on venipuncture and clotted quickly. A chest x-ray revealed a right-sided lung consolidation (Fig. 2). Serum M pneumoniae titers were sent, which later resulted in a Mycoplasma IgG of 0.73 (normal,
Painless Pediatric Priapism and Cough Micah Jacobs, MD,* Mark D. Lo, MD, MS,†‡ and Thomas S. Lendvay, MD, FACS§∥ Abstract: Pediatric priapism can be a medical emergency but is not a common complaint seen in pediatric emergency department. Priapism in a previously healthy child is also rare. We report a case of painless stuttering priapism associated with an acute Mycoplasma pneumoniae infection in a previously healthy boy. Key Words: stuttering priapism, Mycoplasma pneumoniae, urologic emergency
P
riapism is an uncommon presenting complaint in pediatric emergency department and is rarely seen in previously healthy children. The most common etiologies for priapism in children include complications from sickle cell disease, trauma, oncologic sequelae, or medication use. Priapism has been twice described in previous literature in association with Mycoplasma pneumoniae infection.1,2 We present a 10-year-old child who presented with stuttering priapism of unknown etiology, which was ultimately associated with M pneumoniae.
CASE A 10-year-old previously healthy boy presented to the pediatric emergency department of an academic medical center with a complaint of approximately 5 hours of intermittent painless priapism. He had no previous medical issues and he first noted penile edema of the distal shaft that morning without complete engorgement of the corporal bodies. He then had a progressive tumescence of his phallus during the morning. He was able to urinate without difficulty or pain but developed an erection soon after urination that did not resolve. Because of the persistence of his penile swelling and erection, he sought medical care at an outside hospital emergency room. He was subsequently transferred to our pediatric emergency department to receive pediatric subspecialty care secondary to the diagnosis of priapism. The patient denied dysuria, hematuria, penile discharge, penile trauma, or masturbation. He had minimal pain despite his prolonged erection. He noted that his erection was intermittent. At the time of presentation to our pediatric emergency department, he was afebrile but reported a brief fever that had occurred 1 week before presentation. He also reported a cough and upper respiratory symptoms for 1 week before presentation. His previous medical history was not significant for chronic disease. Specifically, he did not have a history of clotting disorders, oncologic processes, medication usage, or sickle cell disease. The patient's twin brother was noted to have had an episode of idiopathic thrombocytopenic purpura in the past from which he fully recovered. There were several sick contacts at home that had recently recovered from upper respiratory illnesses. From the *Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; †Department of Pediatrics, University of Washington; ‡Division of Pediatric Emergency Medicine, Seattle Children's Hospital; §Department of Urology, University of Washington; and ∥Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA. Disclosure: The authors declare no conflict of interest. Reprints: Mark D. Lo, MD, MS, Seattle Children's Hospital, 4800 Sand Point Way NE, M/S B-5513, Seattle, WA 98105 (e‐mail: [email protected]). Copyright © 2015 by Lippincott Williams & Wilkins ISSN: 0749-5161
36
www.pec-online.com
On physical examination, the patient was afebrile with a blood pressure of 105/60, a heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and an oxygen saturation of 96% on room air. The patient had a Tanner stage II with a circumcised penis that was semierect (Fig. 1). Testicular examination revealed descended testes with intact cremasteric reflex bilaterally. His scrotum was nontender with no discoloration of the skin. During the course of the physical examination, his penis became fully erect and did not return to a flaccid state. A ring of subcoronal swelling was present, which the patient confirmed had been present since that morning. He had a dry cough during his examination. The pediatric urology consult service noted that his respiratory examination was significant for crackles on the right on auscultation. He had no respiratory distress at time of examination. Initial laboratory workup in the emergency department included a complete blood cell count, which was significant only for a mildly elevated white blood cell count of 12,300 with 69% neutrophils. A basic metabolic panel was within normal limits. His urinalysis showed no red or white blood cells and was nitrite negative. Of note, his blood was noted to be “thick” on venipuncture and clotted quickly. A chest x-ray revealed a right-sided lung consolidation (Fig. 2). Serum M pneumoniae titers were sent, which later resulted in a Mycoplasma IgG of 0.73 (normal,
