ABSTRACT
A 3-month-old baby girl was brought to the emergency department by her mother who was concerned about bruises. The baby was left in the care of her father overnight while her mother went to work. The next morning, her mother noticed bruises on her left side, shoulders and buttocks. The baby had otherwise been acting normally. Her mother commented that the baby had several bruises in the past on different areas of her body including forehead. There was no history of trauma given except for the bruise she once had on her face as a result of hitting herself with her toy. Her mother mentioned that some of these bruises have been present since birth. Images 120a through 120c show her buttocks, left flank and left shoulder. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig120a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig120b.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig120c.jpg"/>
What is your diagnosis?
Would you recommend any additional testing?
How do you confirm your diagnosis?
274The child has a combination of dermal melanosis (commonly called Mongolian spots) and bruises. Mongolian spots are ill-defined grey to greenish-blue patches that are usually present at birth or develop within the first few weeks of life. Mongolian spots are commonly located on the buttocks or the lumbosacral area. They can be mistaken for bruises due to their colour, especially when they are located on atypical sites. 1 When asked specifically about each of the marks, the mother mentioned the ones on the buttocks were present since birth, consistent with Mongolian spots. The one on her left lateral thigh was also from birth. However the ones on her side as well as her left shoulder were new. The mother stated that she noticed they were tender as well.
An evaluation by a child abuse paediatrician may be valuable in identifying cutaneous mimics of physical abuse, relieving abuse concerns and recognizing children who have mimics but also have been abused as in this child. 2 A thorough history was obtained as well as a physical examination with photography. Marks were noted as either present since birth or of recent onset. Due to the presence of bruises, this child had a skeletal survey that showed multiple acute posterior rib fractures, which are highly specific for abuse. She also had a complete blood count, prothrombin time (PT), partial thromboplastin time (PTT) and liver enzymes, all of which were normal. Head imaging was also normal. There was no history to explain the bruises, and a 3-month-old is not mobile and not able to harm herself with a toy and cause bruises. The diagnosis was therefore physical abuse.
The diagnosis was confirmed when the infant presented for her 2-week follow-up for a repeat skeletal survey. Unlike bruises, Mongolian spots are not tender and do not evolve over time. They usually fade in early childhood but can persist indefinitely. She was examined again and the Mongolian spots that the mother thought were bruises since birth on her buttocks and lateral left thigh remained unchanged. The remaining bruises on her left side and shoulder had resolved. Her repeat skeletal survey showed healing of the posterior rib fractures with no additional fractures.
