Raccoon Eyes Research Articles

A misleading Periorbital Hematoma..Case Report

Periorbital ecchymosis or hematoma is due to extravasations or collections of blood into the periorbital skin and the subcutaneous tissues around the eyes. ‘Spectacle hematoma’ ‘raccoon eyes’ or ‘panda sign’ is a distinctive type of periorbital hematoma. A six year old girl brought in the casualty accompanied by her mother with complain of severe cough, left periorbital blackening, running nose, nose block and mild fever for 7 days. Keywords: Periorbital hematoma, Spectacle hematoma, Sub-conjunctival hemorrhage

Raccoon eyes in cutaneous neonatal lupus syndrome.

Raccoon eyes in cutaneous neonatal lupus syndrome.

A 64-year-old woman with raccoon eyes following kidney biopsy: a case report

BackgroundRaccoon eyes or periorbital ecchymosis is caused by blood tracking into periorbital tissues, which is mostly recognized in injuries of head and neck, basal skull fractures, convexity fractures and facial fractures. It was also reported in systematic disorders, such as multiple myeloma, amyloidosis, Kaposi’s sarcoma, migraine and neuroblastoma. However, it is unusual to see a patient showing periorbital purpura after kidney biopsy with no other ecchymosis. Here, we firstly reported this rare symptom after kidney biopsy in a patient who was finally diagnosed as immunoglobulin light chain (AL) amyloidosis.Case presentationA 64-year old woman was admitted to our clinic with 1.5 years history of sub-nephrotic proteinuria and slowly progressive deterioration of renal function. Laboratory -investigations revealed an M-peak in the λ fraction of IgA and concentrations of serum free-light-chain (FLC) were 44.95 mg/L for κ isotype and 173 mg/L for λ isotype. Unexpectedly the patient showed periorbital purpura 24 h later after kidney biopsy with no more other ecchymosis. Renal biopsy showed massively glomerulosclerosis, interstitial fibrosis with positively Congo red staining in mesangial areas. For fluorescent staining, the kidney tissue showed strongly λ light-chain deposition. The fibrils (8-12 nm in diameter) were confirmed by electron micrograph.ConclusionsThis case firstly reported this rare symptom after the kidney biopsy in a patient who was finally diagnosed as AL amyloidosis. And this unique sign of periorbital ecchymosis warrants more attention as an early cue of amyloidosis.

A 13-year-old systemic lupus erythematosus girl initially presenting with Raccoon eyes and neuropsychiatric manifestations

Background and aim of the workSystemic lupus erythematosus (SLE) is a multisystem autoimmune disease. Although eyes are seldom affected, this case report presents a 13-year-old Iranian girl with Raccoon eyes and neuropsychiatric manifestations as an initial presentation of SLE. Case presentationThe patient was admitted to the pediatric rheumatology inpatient, Mofid Children’s Hospital, Tehran with swelling and ecchymosis around the eyes (Racoon eyes) as well as anorexia, abdominal pain, weight loss, mood disorders and hallucinations. Complete blood count showed normocytic, normochromic anemia, leukopenia, lymphopenia and thrombocytopenia. The C-reactive protein, erythrocyte sedimentation rate, liver and renal functional tests, and urine analysis were normal. The complement levels decreased, antinuclear antibody (ANA) and anti-double stranded DNA (anti-dsDNA) tests were positive. Bilateral pleural effusion and mild pericardial effusion were seen. Bone marrow aspiration showed mild hypocellularity without any evidence of malignancy. The diagnosis of neuropsychiatric SLE (NP-SLE) was held. She was treated by the pulse methyl prednisolone (30 mg/kg/d) and intravenous cyclophosphamide (500 mg/m2), oral prednisolone and hydroxychloroquine. Her appetite improved while hallucination and aggressive behavior decreased. Peri-orbital swelling and ecchymosis decreased. After one year, her appetite became normal; mood disorders, panic, phobic attacks and hallucinations were completely remedied. Swelling and ecchymosis around the eyes were eliminated. Oral prednisolone 10 mgday and hydroxychloroquine (5 mg/kg/day) were continued. ConclusionSLE may present with Raccoon eyes. Rapid detection and treatment of the disease based on clinical symptoms is critical for these patients. Prednisolone and cyclophosphamide are the best choice for treatment of the disease in children.

Predictors and Significance of Orbital Fracture in Traumatic Brain Injury

Background and purpose: Orbital manifestation in traumatic brain injury though uncommon, is one of the major complications of traumatic brain injury that has to be addressed judiciously to prevent permanent visual loss.
 Material and Methods: 211 patients who underwent CT for traumatic brain injury in between September to December 2019 were prospectively examined for the orbital manifestation. Patients who had undergone CT head including orbit with 3D face RECON were only included in our study to remove the bias between fracture line and suture in plain CT scan. CT imaging was evaluated to identify and subtype the orbital fracture.
 Results: Total number of patients was 28, with mean age of 33.82 (SD 17.15) years. Majority of the patients were male which accounted 79% of sample size. There was 78% mild head injury followed by 18% and 4% moderate and severe head injury respectively. The most common type involved among all were blow out fracture and lateral orbital wall fracture. Clinically vision was abnormally around 21% of the cases, abnormal papillary reaction was seen in 25% of the cases around 93% of the cases had raccoon eye at the time of presentation. There was proptosis in around 14% of the patients and subconjunctival hemorrhage was seen in around 93% of the cases. Around 79% of the patients had intact vision at the time of presentation and 3.6% of the patients improved their vision during the course of treatment. Complete globe disruption who required evisceration of the eyeball was 10.7% and those who had abnormal vision at the time of presentation, 7.1% that did not improve their vision.
 Conclusions: orbital manifestations with either type of orbital fracture in traumatic brain injury are useful for the prediction of severity of orbital injury and its clinical outcome. This helps to identify patients in high risk and start early treatment to prevent permanent visual loss.

Evaluation of causes of brain CT scan in patients with minor trauma

BackgroundComputerized tomography (CT) scan is one of the widely used imaging modalities for the diagnosis of anomalies and diseases. Nonetheless, increased exposure to the radiations is one of its overlooked side effects. ObjectiveThe aim of this study was to determine the causes of cerebral CT scan in patients with minor trauma. MethodIn this cross-sectional study, 550 patients with minor head trauma referred to (XXX) were evaluated. The data are collected and completed using a questionnaire comprising of variables such as age, sex, type of trauma, trauma severity, CT scan results, associated symptoms based on NEXUS II, CCHR and NOC criteria and underlying diseases. The data were analyzed using statistical tests and SPSS software version 22. ResultThe mean age of patients was 32.5 years and 62% of patients were male. 67% of the patients visited the hospital on their own. The cause of the trauma in 29% patients was car accident, 19% fall from height and 16.5% conflict. Scalp lesions were seen in 30.5%, hematomas in 4.9%, dizziness in 8.9%, history of comorbidities in 5.8%, episode of vomiting less than 2 in 7.3%, episode of vomiting more than 2 times in 1.1%, headache with score ≥7 in 5.8%, headache with score ≤7 in 23.1%, postoperative forgetfulness in 0.2%, raccoon eyes in 0.2% and nose bleeding in 1.5%. Findings of CT scan were abnormal in 0.2% of patients. The patient's condition declared cleared in 94.5% cleared and 5.5% referred to a neurosurgery. Statistically, CT scan had significant role in predicting the patient's neurosurgery counseling status (P < 0.05). ConclusionThe majority of patients with minor head trauma had normal brain CT scan and was discharged without the need for neurosurgery counseling. Therefore, it seems necessary to reduce brain CT scans without indication to reduce the radiation dose among patients with minor head trauma.

A Baby with Raccoon Eyes

A 10-month-old boy was observed for 2 months’ history of recurrent bruising around the eyes. His parents denied any history of trauma. On ophthalmic examination, bilateral periorbital ecchymosis (raccoon eyes) and subconjunctival hemorrhages were noted (Fig A). Computed tomography shows bilateral extensive mass surrounding bony orbit with widespread skull bone erosion (Fig B). Positron emission tomography-computed tomography revealed a large mass within the left adrenal gland region (Fig C). A biopsy of the abdominal mass and histopathology revealed small round blue cell tumor with background neuropil (Fig D, 40×, arrow).

The Skin Findings Associated with Neurotrauma

Head trauma is a common condition, but often, serious pathological conditions associated with it are hidden. Skin findings in child abuse cases, such as skull base fracture, battle signs, raccoon eye, open head injury, penetrating wounds, traumatic aneurysm of the superficial temporal artery, traumatic carotid cavernous sinus fistula, and fat embolism have been presented in this paper. It is necessary to observe and record skin findings at the time of consultation and to listen to the detailed medical history that resulted in such an injury. It is important to comprehensively diagnose skin findings through medical history, and image inspection.

Osteopetrosis Presenting with Neonatal Thrombocytopenia: A Case Report

Background: Osteopetrosisis an inherited and rare bone disease, characterized by the impairment ofbone modeling and remodeling and the failure of osteoclasts to resorb bone. It also results in skeletal fragility despite increased bone mass, and may cause hematopoietic insufficiency, disturbed tooth eruption, nerve entrapment syndromes, and growth impairment. The infantile form of the disease is the most severe one with a poor prognosis. If untreated, it will result in death by the first decade of life. Case report: A term 10-day-old female neonate with a birth weight of 2850 grams delivered by caesarian section was reported without a history of parents' consanguinity from a healthy, gravida 2, para 1, abort 1 mother with no complication during pregnancy. The newborn admitted to the neonatal ward due to diffuse petechiae, purpura on the skin, and periorbital ecchymosis (raccoon eyes), without any other abnormal significant signs and symptoms. In laboratory findings except for frequent low platelet count as low as 10000-25000, there wasn’t any other abnormalities. Other coagulative tests were within normal ranges. In addition to antibiotics for probable sepsis, platelet transfusion was considered as the treatment, and due to the lack of proper response to the treatment, with suspicious of alloimmune thrombocytopenia, two courses of IV IgG were administered. Eventually, the persistent thrombocytopenia in spite of mentioned treatment led to further investigation , and finally osteopetrosis was diagnosed by the result of brain CTS. The patient was discharged from the hospital with a moderate thrombocytopenia while she needed frequent platelet transfusion. Eventually with bone marrow transplantation, the sign and symptoms of the disease subsided. Conclusion: In persistent and unjustifiable neonatal thrombocytopenia, diagnosis of osteopetrosis should be considered.

Clinical Signs of Basilar Skull Fracture and Their Predictive Value in Diagnosis of This Injury.

Although clinical signs for the diagnosis of basilar skull fracture (BSF) are ambiguous, they are widely used to make decisions on initial interventions involving trauma patients. We aimed to assess the performance of early and late (within 48 hr posttrauma) signs for BSF diagnosis and to verify the correlation between the presence of these signs and head injury severity. We conducted a prospectively designed follow-up study at a referral hospital for trauma care in Sao Paulo, Brazil, and performed structured observations for 48 hr post-blunt head injury in patients aged 12 years or older. The following signs of BSF were considered: raccoon eyes, Battle's sign, otorrhea, and rhinorrhea. Among the 136 enrolled patients (85.3% male; mean age 40 ± 21.4 years), 28 patients (20.6%) had BSF. The clinical signs for the early or late detection of BSF had low accuracy (55.9% vs. 43.4%), specificity (52.8% vs. 30.5%), and positive predictive value (25.7% vs. 27.1%). However, the presence of these signs was correlated to head injury severity, indicated by the Glasgow Coma Scale (p = .041) and Maximum Abbreviated Injury Scale-Head region (p = .002). In view of the low accuracy of these signs, resulting low clinical value of their presence, and their high sensitivity in the late stage, the study results contraindicate the value of BSF signs for making decisions about using the nasal route for the introduction of catheters and tubes in initial trauma care.

Analysis and Clinical Importance of Skull Base Fractures in Adult Patients with Traumatic Brain Injury.

Aims and Objectives:Basal skull fracture (BSF) is rare in head injury (HI) patients and occasionally goes unnoticed which may lead to cerebrospinal fluid (CSF) fistula. With changing trends in HI, there is a need to reassess incidence and pattern of BSF pattern, CSF leak, meningitis, and management protocol, especially in this part of the world where detailed literature is lacking.Subjects and Methods:We closely followed adult patients admitted with BSF in our institute between January 2013 and December 2014. Associated clinical features were recorded. In case of CSF leak, detailed CSF study was done and patients were managed accordingly. Patients with persistent CSF leak were managed surgically.Results:During the study period, 194 of 5041 HI patients had evidence of BSF (3.85%). BSF was most commonly associated with moderate-to-severe HI (73.19%). About 81.44% patients were male and 29.9% were <30 years. Most common cause was road traffic accident (84.54%). Isolated anterior cranial fossa (ACF) fracture was most common (50%). About 63.92% patients had raccoon eyes. Forty-three patients had CSF leak with CSF rhinorrhea being more common. Culture of only 5 patients suggested bacterial meningitis. CSF leak lasted for more than 10 days in 8 patients, of which 4 patients required surgical repair.Conclusions:BSF is rare in victims of HI. It is more common in young adult males. ACF fractures are most common in our setup. Clinical signs of BSF are supportive but not definitive; high resolution computed tomography head is gold standard to detect BSF. CSF leak is rare and most of the cases can be managed conservatively. Leak persisting more than 7–10 days has high risk of developing meningitis and likely to need surgical intervention.

Spontaneous periorbital ecchymosis: a rare presentation of acute lymphoblastic leukaemia

A 45-year-old woman presented with spontaneous discolouration around the left eye for 1 week. She also gave a history of easy fatigability for 1 month. There was no history of...

Bilateral Periorbital Involvement Localized to Eyelids in Lichen Planus Pigmentosus.

Sir, Lichen planus pigmentosus (LPP) usually affects the face and neck of dark-skin phototype individuals having overexposure to sunlight. There are also a few known atypical clinical variants. Here, we document a unique case of LPP affecting both upper and lower eyelids bilaterally presenting as “raccoon eyes.” A 35-year-old male presented with asymptomatic dark slate-gray hyperpigmentation over both eyelids on both sides for the past 1 year. There was no history of trauma, pre-existing dermatosis, or topical and/or systemic medications before the onset of pigmentation. Local cutaneous examination revealed well-defined dark slate-gray hyperpigmented patches chiefly involving both the right and left upper eyelids and medial aspect of both lower eyelids extending to the infraorbital area [Figure 1a and b]. Few brownish-black hyperpigmented patches with atrophic centre were also present on the right side of forehead. Nails and mucosa were normal on examination.Figure 1: (a) Dark slate-gray hyperpigmented patches on both upper eyelids and hyperpigmented patches with atrophic centre on right side of forehead. (b) Slate-gray hyperpigmentation of medial aspect of both lower eyelidsHistopathologic examination of the punch biopsy specimen taken from lower eyelid lesion demonstrated moderately dense superficial perivascular lichenoid lymphocytic infiltrate along with melanophages in papillary dermis with wedge-shaped hypergranulosis and compact orthohyperkeratosis. The dermoepidermal junction showed focal basal cell vacuolization, and scattered necrotic keratinocytes and colloid bodies were seen at the interface [Figure 2]. Based on the clinicopathologic correlation, bilateral eyelid pigmentation was diagnosed as LPP and the atrophic hyperpigmented patches on forehead were considered as lichen planus too (atrophic variant) because LPP is well known to coexist with other cutaneous lesions of LP.Figure 2: Compact orthohyperkeratosis, wedge-shaped hypergranulosis, perivascular lichenoid lymphocytic infiltrate along with focal basal cell vacuolization, and scattered colloid bodies at the interface (H and E, ×400)LPP is a relatively common pigmentary disorder seen in individuals of Fitzpatrick skin type III–V living in tropical countries such as India, middle-east, and Latin America.[1] It chiefly affects the face, neck, and upper limbs with ill-defined slate-gray to brownish-black hyperpigmentated homogenous patches.[1] There are certain rare clinical forms of LPP such as LPP inversus (flexural involvement), blaschkoid, zosteriform, segmental, and mucosal forms reported in literature.[2] In this article, a unique presentation of LPP has been noted which involved both upper and lower eyelids bilaterally, masquerading as “raccoon eyes.” Previously, only 19 cases of LP were reportedly seen to involve eyelid regions, summarized in a recently published article, and none of those cases were the LPP variant of LP.[3] Of note, we could find a single case having ill-defined patches of LPP with periocular distribution in a female.[4] Considering the peculiar involvement of eyelid area, its differential diagnosis includes only a few conditions such as dermal melanocytosis, post-inflammatory hyperpigmentation secondary to atopic dermatitis, allergic contact dermatitis, Riehl's melnosis or pigmented cosmetic dermatitis (PCD), fixed drug eruption (FDE), and tear trough associated with ageing.[5] Among these, PCD is the most important differential diagnosis occurring secondary to application of cosmetics containing allergens such as balsam of Peru, cinnamates and lanolin, or some pigments.[1] Considering that patch testing is not a very useful method to differentiate these two conditions, detailed history, morphology and color of the lesions, and histopathologic demonstration of classical findings of LPP confirm the diagnosis. Treatment modalities for LPP include topical application of mild or potent steroids, tacrolimus, oral administration of dapsone, retinoic acid derivatives, cyclosporine, and phototherapy.[3] For cases of LPP of eyelids, tacrolimus should be used for topical application to avoid ocular side effects of topical steroids. Description of such a unique case further expands the dimension of clinical variants of LPP, warranting its consideration as an important differential diagnosis in all doubtful cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

CHARACTERISTICS OF MODERATE AND SEVERE HEAD INJURIES AT EMERGENCY DEPARTMENT HUE CENTRAL HOSPITAL

Background: Head injury is one of common trauma at ED. It is also main cause of dead and disability of trauma. In Vietnam, accident traffic is most common cause of head injury. ED admits a large number of moderate and severe head injury patients everyday. These injuries can result in physical and mental consequences because of traumatic brain injury (TBI); burden to family and society. However, there is not a consensus in statistics of cause, severe symptom, risk factors to severity and short-term outcome at these patients. Objectives: assessement of cause, symptom and risk factors of moderate and severe head injuries as well as presentations of CT scanner. Materials and Methods: This is a cross sectional study. Population of interest: Patients with trauma who transported to ED of Hue Central Hospital and classified as moderate and severe head injuries were chosen conveniently into the study. Inclusion criteria: Patients with trauma by any reason; Glasgow score≤13, Sample size: There was not limitation of case number. Results: There were 50 patients with severe and moderate head injury. Main cause of trauma was traffic accident (92.2%). Patients were transported to ED by private vehicles (84,3%). Mean age of male was 38.20±14.28, female was 33.00±17.82 (p&gt;0.05). Most of accident were not witnessed by family and not rescued by bystanders. There was an evaluable concentration of plasma ethanol in 88.2% of patients with mean level of 33.99±21.88 mmol/L in male and 12.90±19.98 mmol/L in female (p&lt;0.05). Ethanol levels in severe head trauma were lower than ones in moderate head trauma (p&lt;0.001). Ethanol levels were not different in patients with different lesions on CT scanners (p&gt;0.05). It existed a correlation between Glasgow score and ethanol levels (r=0.43, p&lt;0.01). Expired rate of patient at ED was 21.6%. Conclusion: Main cause of trauma was traffic accident (99.2%). There were 88.2% of patients used ethanol before trauma; 15.7% of patients were transported by ambulance. There were 64.7% with headache; amnesia of accident 82.4%; vomiting 78.4%; scalp wound 45.1%; ear bleeding 7.8%; nose bleeding 7.8%; raccoon eye 19.6%. It did not exist a difference of ethanol levels in different lesions on head CT scanner. Expired rate of patient at ED was 21.6%. Key words: head injury, traffic accident, ethanol, Glasgow

Proptosis in a previously well five-year-old boy

Neuroblastoma metastasis. Ophthalmic findings may be the first presentation of a neuroblastoma which is the commonest paediatric tumour to metastasise to the orbit. The primary tumour is usually intraabdominal. Approximately 10–20% of children will have orbital metastases [1Ahmed S. Goel S. Khandwala M. et al.Neuroblastoma with orbital metastasis: ophthalmic presentation and role of the ophthalmologists.Eye. 2006; 20: 466-470Crossref PubMed Scopus (36) Google Scholar, 2Dubois S.G. Kalka Y. Lukens J.N. et al.Metastatic sites in stage IV and IVS neuroblastoma correlate with age, tumour biology, and survival.J Pediatr Hematol Oncol. 1999; 21: 181-189Crossref PubMed Scopus (308) Google Scholar] and up to 50% are bilateral [3Chung E.M. Murphey M.D. Specht C.S. et al.Pediatric orbit tumours and tumour like lesions: osseous lesions of the orbit.Radiographics. 2008; 28: 1193-1214Crossref PubMed Scopus (54) Google Scholar, 4Alfano J.E. Ophthalmological aspects of neuroblastomatosis: a study of 53 verified cases.Trans Am Acad Ophthalmol Otolaryngol. 1968; 72: 830-848PubMed Google Scholar, 5Altonbary Y. Mansour A.K. Sarhan M. et al.Proptosis is a pediatric dilemma.Ann Pediatr Child Health. 2015; 3: 1066Google Scholar]. Proptosis and ecchymosis (“raccoon eyes”) are the commonest ocular manifestations [[3]Chung E.M. Murphey M.D. Specht C.S. et al.Pediatric orbit tumours and tumour like lesions: osseous lesions of the orbit.Radiographics. 2008; 28: 1193-1214Crossref PubMed Scopus (54) Google Scholar]. The most common cause of proptosis in a child is orbital cellulitis [[5]Altonbary Y. Mansour A.K. Sarhan M. et al.Proptosis is a pediatric dilemma.Ann Pediatr Child Health. 2015; 3: 1066Google Scholar]. Histiocytosis, haemangioma or lymphangioma are further benign causes. Malignant aetiologies include rhabdomyosarcoma, Ewing’s sarcoma, lymphoma and metastases from a neuroblastoma, bone tumours or leukaemia [[5]Altonbary Y. Mansour A.K. Sarhan M. et al.Proptosis is a pediatric dilemma.Ann Pediatr Child Health. 2015; 3: 1066Google Scholar]. Typical CT or MRI features are an extra-conal soft tissue mass arising from the wall of the orbit [[8]Lonergan G.J. Schwab C.M. Suarex E.S. et al.Neuroblastoma, ganglioneuroblastoma, and ganglioneuroma: Radiologic-Pathologic Correlation.Radiographics. 2002; 22: 911-934Crossref PubMed Scopus (478) Google Scholar]. As in this patient, it can be locally aggressive extending into the infratemporal fossa structures or intra-cranially, with bony destruction of the roof and wall of the orbit and resultant bony spiculation [3Chung E.M. Murphey M.D. Specht C.S. et al.Pediatric orbit tumours and tumour like lesions: osseous lesions of the orbit.Radiographics. 2008; 28: 1193-1214Crossref PubMed Scopus (54) Google Scholar, 6Wells R.G. Sty J.R. Gonnering R.S. Imaging of the pediatric eye and orbit.Radiographics. 1989; 9: 1023-1044Crossref PubMed Scopus (14) Google Scholar, 7Lallemand D.P. Brasch R.C. Char D.H. et al.Orbital tumours in children: characterisation by computed tomography.Radiology. 1984; 151: 85-88Crossref PubMed Scopus (8) Google Scholar]. The mass may be unilateral or bilateral, unlike a rhabdomyosarcoma which is typically unilateral [[3]Chung E.M. Murphey M.D. Specht C.S. et al.Pediatric orbit tumours and tumour like lesions: osseous lesions of the orbit.Radiographics. 2008; 28: 1193-1214Crossref PubMed Scopus (54) Google Scholar]. Furthermore, rhabdomyosarcoma may involve anterior pre-septal orbital structures but a neuroblastoma will usually not [[3]Chung E.M. Murphey M.D. Specht C.S. et al.Pediatric orbit tumours and tumour like lesions: osseous lesions of the orbit.Radiographics. 2008; 28: 1193-1214Crossref PubMed Scopus (54) Google Scholar]. Neuroblastomas can cause dural and leptomeningeal metastases, with involvement of the skull causing diastasis of affected sutures [3Chung E.M. Murphey M.D. Specht C.S. et al.Pediatric orbit tumours and tumour like lesions: osseous lesions of the orbit.Radiographics. 2008; 28: 1193-1214Crossref PubMed Scopus (54) Google Scholar, 8Lonergan G.J. Schwab C.M. Suarex E.S. et al.Neuroblastoma, ganglioneuroblastoma, and ganglioneuroma: Radiologic-Pathologic Correlation.Radiographics. 2002; 22: 911-934Crossref PubMed Scopus (478) Google Scholar]. This child had clinical, radiological and pathological findings consistent with metastatic neuroblastoma and an MRI abdomen (Fig. 2) revealed a left adrenal primary site. Proptosis in a previously well five-year-old boyJournal of Clinical NeuroscienceVol. 34PreviewA five-year-old boy presented with a one-week history of left-sided proptosis and retro orbital pain, with no prior medical or surgical history. On examination, there was left-sided proptosis with no visual field defect or other neurological abnormality. Full blood count, electrolytes and inflammatory markers were unremarkable. Full-Text PDF

A Case of Ottorhea Induced by a Fall From a Skateboard

HISTORY: 19 year old male with negative past medical history presented to the Student Health Center with right jaw pain after a fall from his skateboard. He lost control on a downhill sidewalk and fell directly onto his chin. He was not wearing a helmet. He also complained of blood coming from his right ear and decreased ability to hear on right. He denied loss of consciousness, headache, focal neurologic deficits, vision changes, nausea, vomiting, abdominal pain, chest pain, shortness of breath, neck pain, back pain, or hip pain. PHYSICAL EXAMINATION: The patient was hemodynamicaly stable and in no acute distress. Pupils were equal, round and reactive. He had a 2.5cm superficial laceration to chin. There was tenderness over the right TMJ and decreased ability to open mouth. He had bleeding from the right ear canal. Otoscopic exam revealed what appeared to be a small bump with associated laceration, oozing blood. There was no hemotympany. No clear leakage from ears or nares. No battle’s sign or raccoon eyes. There were no other remarkable findings, but given the extent of his injuries, the patient was sent to the Emergency Department (ED) for further evaluation. DIFFERENTIAL DIAGNOSIS:1.Basilar skull fracture. 2. Mandibular fracture. 3. Cervical spine fracture. 4. Foreign body introduced into ear canal from fall. TEST AND RESULTS: Cat Scan Head, Cervical Spine and Maxillo-facial bones FINAL WORKING DIAGNOSIS: Comminuted fracture of the right mandibular neck with anterior angulation of the mandibular condyle and dislocation of the TMJ. Additionally, there is fracture of the anterior bony wall of the External Auditory Canal. No other acute abnormality noted. These findings combined with a chin laceration suggest impact on the chin, with traumatic impaction of the mandibular condyle onto the mandibular fossa of the right temporal bone. TREATMENT AND OUTCOMES: The chin laceration was repaired in the ED. Neurosurgery was consulted as there was concern for basilar skull fracture. Per their recommendation, there was no need for any neurosurgical intervention. Plastic surgery and ENT were also consulted. He received a prescription for ciprofloxaxin otic drops and then followed up with ENT and Plastic Surgery as an outpatient. He had wire fixation with arch bars to treat the mandibular fracture and has not had any complications to date.

Lichen planus pigmentosus masquerading as ‘Raccoon eyes’

Lichen planus pigmentosus masquerading as ‘Raccoon eyes’

Curious case of raccoon eye under general anaesthesia.

Curious case of raccoon eye under general anaesthesia.

Blue Tick Mongrel: Pacing the Pittsylvania County Line

Blue Tick MongrelPacing the Pittsylvania County Line Annie Woodford (bio) This blacktop tells of possum scent But I lead myself to a red dirt rising, Where lanky pine trees bend And whistle in wind. I stop and sniff, then pace Again, a dog intent on going somewhere. I travel with squared haunches Past tobacco fields all yellow With a tawny scent and let The bumblebee buzz me by. Even in sleep my paws twitch With the dream of this plateau: I’m running to the creaking pines, Orange with dust, padding over silent straw. Let me be I tell the truck: I left my shaded yard months ago. Strange men with smokehouses Shall not capture me though at night I bay For hearths and table scraps I’ve forsaken. I am the hound you find pacing, up Into the curve of scarlet horizons. My blood tells in the way I hang my head And move a little side-ways That I have a coyote way of knowing— [End Page 106] Somewhere close there’s a circle Of raccoon eyes, high Among pines that praise the sky. [End Page 107] Annie Woodford Annie Woodford is originally from Henry County, Virginia. A graduate of Hollins College’s MA program in Creative Writing, she now lives in Roanoke City, Virginia and teaches developmental English at Virginia Western Community College. Copyright © 2015 Berea College

“Blind spots” in forensic autopsy: Improved detection of retrobulbar hemorrhage and orbital lesions by postmortem computed tomography (PMCT)

The purpose of this study was to correlate the occurrence of retrobulbar hemorrhage (RBH) with mechanism of injury, external signs and autopsy findings to postmortem computed tomography (PMCT). Six-teen subjects presented with RBH and underwent PMCT, external inspection and conventional autopsy. External inspection was evaluated for findings of the bulbs, black eye, raccoon eyes and Battle's sign. Fractures of the viscerocranium, orbital lesions and RBH were evaluated by PMCT. Autopsy and PMCT was evaluated for orbital roof and basilar skull fracture. The leading manner of death was accident with central regulatory failure in cases of RBH (31.25%). Imaging showed a high sensitivity in detection of orbital roof and basilar skull fractures (100%), but was less specific compared to autopsy. Volume of RBH (0.1-2.4ml) correlated positively to the presence of Battle's sign (p<0.06) and the postmortem interval. Ecchymosis on external inspection correlated with RBH. There was a statistical significant correlation between bulbar lesion and RBH. Orbital roof fracture count weakly correlated with the total PMCT derived RBH volume. Maxillary hemosinus correlated to maxillary fractures, but not to RBH. RBH are a specific finding in forensically relevant head trauma. PMCT is an excellent tool in detecting and quantifying morphological trauma findings particularly in the viscerocranium, one of the most relevant "blind spots" of classic autopsy. PMCT was superior in detecting osseous lesions, scrutinizing autopsy as the gold standard.