ABSTRACT
This 3-year-old child was brought to the emergency department in the middle of the night by her grandmother. She said the girl was fine when she went to bed. She heard the child coughing in the night and when she checked her, the girl looked like this (Image 2).
What signs do you notice?
What history would you take?
What is the differential diagnosis?
https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig2.jpg"/>4The girl has bilateral subconjunctival haemorrhages with ecchymoses of the upper and lower eyelids and a slight degree of congestion and oedema of the orbit. She also has fine petechiae of the face.
The doctor needs to take a full medical history, in particular asking details of the nature of the cough. A social history should also be taken and health and social care records checked for previous safeguarding concerns.
Child abuse has been recognized as a cause of subconjunctival haemorrhage. Cases with non-accidental intracranial injury and fractures have presented with a single small unilateral haemorrhage when further investigations such as brain imaging and skeletal survey are done. Other causes of subconjunctival haemorrhage include blood dyscrasias and coagulopathies, malignancies such as metastatic neuroblastoma or rhabdomyosarcoma and leukaemia, conjunctivitis and traumatic asphyxia from severe chest compression. Bouts of violent coughing in pertussis, as in this case, were well recognized as a cause of severe subconjunctival haemorrhages when the infection was more common. However, the presence of pertussis does not rule out non-accidental injury, so appropriate assessments should still be undertaken in suspicious cases. 1–3
