Figure – This bruise in an infant boy's right popliteal fossa was one of a number of unexplained bruises, which raised suspicion for abuse.
A 3-month-old boy was brought by his mother to his busy primary care physician's office for follow-up of bronchiolitis when numerous bruises were noted. The mother said that the infant had a 1-week history of unexplained bruising, petechiae, and irritability. The child was referred to the local emergency department (ED) because of concern for nonaccidental trauma.
On questioning, the mother stated that a bruise over the child's right cheek resulted from a bump to the head that he sustained while being carried over his father's shoulder and sucking on a pacifier. She did not know how he had acquired the other bruises.
The child was the product of a full-term pregnancy. The mother denied use of any drugs or any history of illness during her pregnancy; however, results of maternal testing for group B streptococci were positive. Birth weight was 2.9 kg (15th percentile) and length was 51 cm (50th percentile). The infant had a vitamin K injection in the newborn nursery. In addition, he had a nuchal cord and had to remain in the neonatal ICU for 5 days because of difficulty in breathing. Circumcision was performed during this stay; there was no significant bleeding.
The infant's medical history was significant only for bronchiolitis 3 weeks before this visit; he had recently completed a 10-day course of amoxicillin. He had been formula-fed since birth and was currently taking no medications. Growth and development were within normal limits. Family history was significant for cystic fibrosis (CF) in a maternal great-uncle (although this was revealed only after extensive questioning). There was no other pertinent medical or social history.
Physical examination in the ED revealed a temperature of 36.4°C (97.5°F); heart rate, 131 beats per minute; respiration rate, 36 breaths per minute; length, 54 cm (below the 3rd percentile); head circumference, 39.5 cm (10th percentile); and weight, 5.95 kg (50th percentile). Examination of the head, ears, eyes, nose, and throat revealed petechiae on the hard palate, bilateral otitis media, and anterior cervical chain lymphadenopathy. Lungs were clear to auscultation. Purpuric/ecchymotic lesions were noted in the perioral, buccal, and occipital regions. The patient also had similar bruises in the right popliteal fossa (Figure) and on the left thigh and back. The remainder of the physical findings were normal.
Do you suspect abuse—or a medical cause?
Answer and discussion on Next Page
1. Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119:1232-1241.
2. Per H, Kumandas S, Ozdemir MA, et al. Intracranial hemorrhage due to late hemorrhagic disease in two siblings. J Emerg Med. 2006;31:49-52.
3. Bergman AS, Blessing-Moore J, O'Leary J, Alvarez C. An unexpected complication of cystic fibrosis. Chest. 1980;78:802.
4. Carpentieri U, Gustavson LP, Haggard ME. Misdiagnosis of neglect in a child with bleeding disorder and cystic fibrosis. South Med J. 1978;71:854-855.
5. O'Hare AE, Eden OB. Bleeding disorders and non-accidental injury. Arch Dis Child. 1984;59:860-864.