Case 84

A 4-month-old baby girl presented with new-onset seizure-like movements. She began having rhythmic jerking of the right side of the body on the morning of presentation. She was previously healthy and has been afebrile. On physical examination, she was noted to have the lesion shown (Image 84) on her left leg. Her physical examination was otherwise normal. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig84.jpg"/>

What is your diagnosis of the lesion on her leg?

What is the management for the skin lesion?

What further workup is needed?

190

The lesion pictured is a human bite mark. Human bite marks are typically located on the face, upper extremities and trunk. Human teeth may leave superficial abrasions or lacerations surrounded by soft tissue bruising. They generally appear as a straight line, are circular or oval shaped. Canine teeth leave the most prominent marks in the shape of a triangle or point. All human bite marks should raise suspicion for abuse. ¹

Bite marks should be photographed individually. Serial photographs over several days may help a forensic odontologist evaluate the case. Photographs both with and without a ruler or scale in place should be taken. Intercanine distances measuring 3.5–4 cm are suspicious for bite marks left by an adult. Primary dentition (under 6 years old) typically has intercanine distances less than or equal to 3 cm. It has been shown that age, sex and race differences are insignificant in ages over 12 years. Each photograph should be taken with the camera lens positioned perpendicular to the skin to avoid distortion. Photographs should be taken by a person who is experienced with the camera and equipment being used. If available, pictures should be taken by a trained medical photographer. Location of bite marks should be documented on a body diagram and included in the medical record along with a detailed written description of the lesions. ²

The patient presented in the scenario needed to be evaluated for abuse because of the presence of the bite mark. It is important to take a detailed history and perform a full physical including a head-to-toe skin exam. A skeletal survey to evaluate for new and healing fractures, dilated retinal exam for retinal haemorrhages and head imaging are all warranted, especially considering this infant’s age and her presentation with seizure-like movement.