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Streptococcus pneumoniae infections occur more frequently in children infected with HIV than in immunocompetent children. Bacteremia, sinusitis, pneumonia, and meningitis are the most common serious presentations [1]. We report a case of testicular abscess due to S. pneumoniae in an HIV-infected infant. A 15-week-old male with vertically transmitted HIV infection was admitted to the hospital because of fever, irritability, and swelling and erythema of the scrotum of 1 day's duration. He had been delivered at term by elective cesarean section; his 31-yearold mother had not been treated with zidovudine during pregnancy. Twenty-four hours after birth, he was found to be positive for HIV by PCR. Therapy with oral zidovudine and prophylaxis with trimethoprim-sulfamethoxazole were started when the patient was 1 week and 4 weeks of age, respectively. The infant developed a urinary tract infection due to Escherichia coli at 1 month of age and Streptococcus bovis meningitis at 9 weeks of age. Evidence of rapidly progressing HIV disease included failure to thrive, hepatosplenomegaly, spastic quadriparesis, and an absolute CD4 cell count of 680/mm 3 (CD4 cells, 22%). Didanosine was added to the regimen when he was 3 months of age. On admission, the patient was irritable but did not appear toxic. Vital signs were temperature, 39.9°C; respiration rate, 38; and heart rate, 126. He weighed 4 kg (below the third percentile). In addition to the previously noted findings, the physical examination was remarkable for an enlarged, tender, and erythematous right scrotum (-2.5 cm in diameter), without detectable abnormalities on transillumination. Tests revealed the following significant laboratory values: hemoglobin, 9.1 g/dL; WBCs, 2,060/mm 3 (25% neutrophils, 65% band forms, 8% lymphocytes, and 2% metamyelocytes); alanine aminotransferase, 340 U/L; aspartate aminotransferase, 652 U/L; total bilirubin, 1.4 mg/dL; and alkaline phosphatase, 182 U/L. The results of urinalysis were normal. Cultures of blood and urine were performed, and the patient started treatment with parenteral ceftriaxone (75 mg/[kg • d]). A chest roentgenogram showed a rightupper-lobe infiltrate, which had been noted on previous films. Testicular imaging studies included a nuclear scan with increased tracer flow to the right scrotum, indicative of inflammation (there was no evidence of testicular torsion) and an ultrasonogram that revealed a complex mass (0.5 X 2.5 cm) adjacent to the right testis, consistent with an abscess. On the second hospital day, cultures of blood drawn on admission yielded gram-positive cocci in pairs that were later identified as penicillin-susceptible S. pneumoniae; the urine culture was negative. Therapy was changed to intravenous penicillin G (150,000 U/[kg • d]). The patient was evaluated by a urology consultant on hospital day 2, but aspiration was not attempted because the fever and local signs of inflammation had decreased significantly after the patient began receiving antibiotic therapy. Follow-up blood cultures performed on day 2 after admission remained negative. After completion of a 14-day course of antibiotic therapy, the results of a scrotal examination were normal. Impairment of humoral immunity is an early feature of HIV infection and may account for the high incidence of invasive bacterial disease seen in populations of both children and adults infected with HIV [2, 3]. Serious bacterial infection was the AIDS indicator disease in 13% of 1,535 cases of AIDS in children reported to the Pediatric HIV/AIDS Surveillance Unit of the New York City Department of Health as of September 1995 [4]. In the largest prospective study to date, S. pneumoniae accounted for 21 (31.8%) of 66 laboratory-proven serious bacterial infections in a cohort of 372 HIV-infected children [5]. Previous studies [reviewed in 6] have shown that HIV-infected individuals have impaired mucosal immunity, decreased phagocytic activity, and selective defects in IgG2 responses, which may explain the high incidence of infections due to S. pneumoniae and other encapsulated pathogens in this population. Infants with vertically transmitted HIV infection may be at particularly high risk for bacterial infections because of immaturity of the fetal-neonatal immune system at the time of HIV infection. The finding of an enlarged, tender scrotum in a prepubertal child suggests either testicular torsion or incarcerated hernia, and diagnostic evaluation is directed at ruling out these acute entities [7]. Pyogenic epididymo-orchitis is an unusual finding in this age group, and few cases have been reported; pathogens isolated in these cases include Pseudomonas aeruginosa, Salmonella enteritidis, and Haemophilus influenzae [8-10]. Testicular abscesses are thought to occur either through hematogenous spread of organisms or, in the presence of urinary tract infection, by reflux through the vas deferens [7]. In our case, although the patient's scrotum was not surgically explored, the physical and sonographic findings consistent with a testicular abscess and concomitant bacteremia are strong evidence that S. pneumoniae was the causative pathogen. Management of scrotal abscess usually involves a combination of surgical drainage and systemic antibiotic therapy. As the findings in this case illustrate, medical therapy alone may at times be adequate, even for an immunocompromised host.

Testicular Abscess Due to Streptococcus pneumoniae in an Infant with Human Immunodeficiency Virus Infection