Pack of ice: grey scale sign of testicular torsion.

To cite: Artul S, Fahoum B, Khoury R, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013202734 DESCRIPTION A 21-year-old man presented to the emergency department because 2 days prior to presentation, he was with pain and enlargement of right scrotum. He had no remarkable clinical history. On physical examination, he was afebrile, oedema and redness of right scrotum. Laboratory tests showed leucocitosis up to 14 000 with a left shift. Ultrasound (US) of the right scrotum (figure 1) showed enlarged, oedematous and heterogeneous testis. At surgery he was found to have torsion of 360°, the testis had some viable tissues and therefore orchiopexy was performed. This sonographic finding ‘heterogeneous testis’ in our case merits the name of ‘pack of ice’ to its resemblance to the polar pack of ice (figure 2). The US plays an important role in helping differentiate acute epididymo-orchitis from testicular torsion, which is a surgical emergency. Both manifest with acute pain and swelling. The role of colour Doppler and power Doppler US in the diagnosis of acute testicular torsion is well established with sensitivity and specificity of 96.8% and 97.9%. On the other hand, grey scale ultrasound findings vary with the duration and degree of rotation of the spermatic cord, they are non-specific for testicular torsion and often the testis appear normal if the torsion has just occurred. In our case, the heterogeneity ‘pack of ice’ represents varying degrees of ischaemia: the hypoechoic lesions represent infarcted tissue and the hyperechoic parts represent the viable tissue. Because grey-scale US findings of torsion are often non-specific, the sign of ‘pack of ice’ when present could be a hallmark of torsion.