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Endgames Case Review

Acute enlargement of a vascular plaque and gait changes in a young girl

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4679 (Published 28 November 2018) Cite this as: BMJ 2018;363:k4679
  1. Kathleen T Tedesco, medical student1,
  2. Jay Sarthy, paediatric haematology-oncology fellow2,
  3. Navin Pinto, assistant professor of paediatrics and haematology-oncology2,
  4. Markus D Boos, assistant professor of paediatrics and dermatology3
  1. 1Albany Medical College; Albany, NY, USA
  2. 2Division of Hematology-Oncology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital; Seattle, WA, USA
  3. 3Division of Dermatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital; Seattle, WA, USA
  1. Correspondence to M Boos markus.boos{at}seattlechildrens.org

A 15 month old girl presented to the emergency department with a one week history of unsteady gait and approximately three to four unexplained falls each day. She had been walking independently and without difficulty since she was 12 months old. At birth, she had a broad pink patch on the right medial buttock, which had been diagnosed on clinical examination as a congenital haemangioma. The site had grown proportionally with the patient until these symptoms started, when this vascular stain became acutely indurated, and a contiguous, erythematous plaque appeared superiorly, overlying the sacrum. On examination, a swollen, violaceous, warm, subcutaneous plaque with superimposed telangiectases was noted overlaying the sacrum. This extended to the right buttock, where an accompanying pink-purple stain was present (fig 1). No thrills or pulsations were noted. Neurological examination showed no paralysis. Relevant laboratory findings are shown in table 1.

Fig 1

A swollen, violaceous, subcutaneous plaque overlaying the sacrum with subtle overlaying telangiectases (arrow), extending contiguously to the right buttock with a more prominent vascular stain (arrowhead)

View this table:
Table 1

Relevant investigation findings

Questions

  1. What are the differential diagnoses of lumbosacral swelling in children?

  2. What is the most likely diagnosis?

  3. How would you manage this patient?

Answers

1. What are the differential diagnoses of lumbosacral swelling in children?

The differential diagnoses for paediatric lumbosacral swelling include congenital haemangioma, deep infantile haemangioma, kaposiform haemangioendothelioma (KHE), sacral meningocele, lipoma, dermatofibrosarcoma protuberans, sacrococcygeal teratoma (SCT), rectal abscess, and cellulitis. KHE and non-accidental trauma should also be considered when a child …

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