An infant with multiple hemangiomas showing favorable prognosis

Abstract

A 36‐day‐old baby with a 1‐month history of cough, dyspnea, fever, and failure to thrive was seen by the pediatric clinic of SÛişli Etfal Hospital. The patient was sent to the dermatology clinic because of widespread red spots on her body. Dermatologic examination revealed discrete, dark red, nonblanching, angiomatous lesions (2 mm to 2 cm) on the head, trunk, and extremities ( Fig. 1). In addition, there were a few such lesions in the oral mucosa, on the gingivae and hard palate, and on the labia minora in the genital area. Ophthalmologic examination revealed a few angiomatous spots on the inferior lid of the right eye, but the conjunctival mucosae and fundus were normal. All these lesions had existed since birth and had progressively increased.Patient before treatment. There are multiple hemangiomas on the trunk and a large one on the left wristimageAt the initial physical examination, the baby girl weighed 4.150 kg (25–50th percentile), had a height of 52 cm (10th percentile),and a head circumference of 34.5 cm (25th percentile). The rectal temperature was 37.6 °C. The respiratory rate per minute was 44 and the beat per minute was 48. She had a long expiration, bilateral sibilant and fine wet rales, and coarse rhonchi on auscultation of the lung. The liver was palpable 1 cm below the costal margin. The rest of the general examination was unremarkable.Initial routine laboratory tests showed a red blood cell count of 3688 × 103/mm3, a hemoglobin level of 10.90 g/dL, a hematocrit of 32.31, a thrombocyte count of 654.000, a white blood cell count of 12,060/mm3, aspartate transferase (AST) 40, alanine aminotransferase (ALT) 57, alkaline phosphatase (ALP) 192, total bilirubin 1.50 mg/dL, direct bilirubin 0.69 mg/dL, indirect bilirubin 0.81 mg/dL, total protein 5.7 g/dL, and albumin/globulin rate of 2.2. Serologic tests of hepatitis A and B were negative.Histopathologic examination of a cutaneous skin biopsy specimen revealed numerous capillary lumina including erythrocytes in the papillary and deep dermis. No nuclear atypia and mitotic figures were observed.On thorax computerized tomography (CT), on the left inferior lobe of the lung, irregular pleural thickening, reduced left lung volume, and increased right lung aeration were seen. These findings were consistent with bronchopneumonia. Cranial CT results were assessed as normal. On abdominal ultrasound, the liver parenchyma had dilated vascular structures and multiple hypoechoic areas consistent with multicentric hemangiomatosis ( Fig. 2).Ultrasonography of the liver before treatment. Multiple hypoechoic areas are seen , varying from 10 to 25 mm in diameterimageThe patient was diagnosed as having benign neonatal hemangiomatosis. Respiratory symptoms and pulmonary signs were assessed in favor of bronchopneumonia. Antibiotic therapy with ampicillin + sulbactam for the respiratory disease and 2 mg/kg/day intravenous (IV) methylprednisolone for only 12 days, which was replaced on discharge from hospital with oral methylprednisolone at the same dose. On follow‐up, the skin lesions had begun to fade ( Fig. 3), and had resolved almost completely after 2 months ( Fig. 4). Because of the liver lesions, she remains on the same dose of oral medication. No medical problems are evident.Cutaneous hemangiomas after 1 month of therapyimageCutaneous hemangiomas after 2 months of therapy. There is complete resolutionimage