Zgraj et al. Journal of Medical Case Reports 2011, 5:576 http://www.jmedicalcasereports.com/content/5/1/576 like that of our patient, is usually outside the tunica and hence the blood supply via the testicular artery is pre- served. Although a left-sided hydrocele was diagnosed 17 days prior to this admission, no obvious hydrocele was noted at the time of surgery. Whether the initial swelling was due to a subacute phase of the disease pro- cess or truly was an isolated hydrocele that resolved spontaneously over this short period of time is not clear. Neonatal testicular torsion is a well-recognized condi- tion. Patients present with unilateral, often painless scrotal swelling and erythema of overlying skin. The management of this condition is controversial. Some surgeons recommend immediate exploration whereas others prefer conservative management [8]. Paratesticu- lar abscess (or scrotal abscess) has been reported to mimic neonatal torsion. We elected to proceed to immediate surgical exploration in this baby because the possibility of a missed torsion complicated by a scrotal abscess could not be safely ruled out. This immediate surgical approach allowed us to address the unexpected Fournier gangrene early with minimal soft tissue exci- sion and primary wound closure. No radiological inves- tigations were performed, as the presence of an abscess and systemic signs of sepsis necessitated immediate sur- gical exploration. Although the initial literature advocates early aggressive surgical debridement of Fournier gangrene wounds, a recent report shows a successful outcome with a more conservative and selective surgical debridement [4]. When small babies with acute onset of scrotal swelling are assessed, it is important to exclude testicular pathology. If an experienced pediatric surgeon is not readily available, an ultrasound scan may be useful to exclude common pathologies such as an obstructed hernia, tense hydrocele, or hydrocele of the cord. When the testis is clearly palp- able with no obvious pathology and scrotal wall edema or erythema is the main finding, Fournier gangrene should be considered in the differential diagnosis. We recommend an early surgical approach, first to exclude torsion of the testis and then to debride the involved region. However, the need for aggressive wide debridement appears to be unnecessary in localized disease as long as adequate anti- biotic coverage is provided. We recommend more than one antibiotic coverage, including one specifically targeted toward S. aureus. Both Enterococcus and S. aureus have been implicated as the causative organisms of Fournier gangrene in previous reports [2,11]. Conclusions Fournier gangrene of the scrotum is extremely rare in newborns but should be considered as part of the differ- ential diagnosis in the clinical management of the acute scrotum. If it is considered a possibility, then immediate Page 3 of 3 referral to a dedicated pediatric surgical unit is indicated. Consent Written informed consent was obtained from the patient’s parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Author details 1Department of Paediatric Surgery, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland. 2Department of Pathology, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland. Authors’ contributions OZ gathered patient data, performed a literature search, calculated data from previous articles, and wrote the core of the manuscript. SP analyzed the patient’s presentation in detail and made a major contribution to the manuscript, especially the Discussion section. MO’S performed a histological examination of specimens, photographed them, prepared the figure and legend, contributed in interpreting histological findings in view of the clinical presentation, and made corrections to the manuscript with special consideration to international histological nomenclature. FQ was the consultant in charge of this case, made the intra-operative diagnosis, directed the management, and finalized the manuscript, shaping the final conclusions. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 3 May 2011 Accepted: 12 December 2011 Published: 12 December 2011 References 1. Noseworthy J: Testicular torsion. In Pediatric Surgery.. 3 edition. Edited by: Ashcraft KW, Murphy JP, Sharp RL, Sigalet DL, Snyder CL. 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