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An Unusual Bruise on the Face of a 20-month-old Boy

An Unusual Bruise on the Face of a 20-month-old Boy

  • MayFlower is a 20-month-old boy with a >1 month history of an unusual bruise that arose after he bumped his face against his toy chest 4-5 weeks ago. He is otherwise totally well.
  • On the young boy's face there is a very firm reddish-blue nodule that feels like there are several lumps within it.
  • Past medical history is non-contributory. Physical examination: There is A 2.5-cm firm reddish-blue nodular lesion on his left upper cheek. There is no hepatosplenomegaly. He is without any other skin lesions. The only test ordered is a CBC which reveals a normal differential and normal indices.
  • A close-up view...A very firm reddish-blue nodule that feels like there are several lumps within it. There is a “tent” appearance when skin is stretched.
  • Time to figure a differential diagnosis. We have a well child with a lump/bump after well documented accidental trauma. As bad as this appears, there is nothing to make us think this is a malignant lesion. So, do you have a differential diagnosis for lumps and bumps in childhood? Which lump is the most common?
  • Here is my differential diagnosis: Fibroma, neurofibroma, lipoma, lymphangioma, juvenile xanthogranuloma, granuloma annulare, mastocytomas, malignant tumor (usually sarcomas), epithelial inclusion cyst, pilomatrixoma, miscellaneous.
  • What is your differential diagnosis of a reddish-purple lump on a young child's face after known trauma?
  • Answer: Pilomatrixoma (calcifying epithelioma of Malherbe). Second most common superficial lump in children after epidermal inclusion cysts. Is an acquired hamartoma of hair follicle origin (ie, a nonmalignant mutation of hair matrix cells). Hard, multilobular papule or nodule with a bluish color. Stretching of skin over lesion can give a “tent” appearance.
  • Treatment: surgical excision is best for pilomatrixoma. Histology of pilomatrixoma reveals sheets of compact basal cells alternating with “ghost” or “shadow” cells. There is often calcification.
  • Differential diagnosis in order of occurrence: Epithelial inclusion cyst - 59%, pilomatrixoma - 10%, miscellaneous - 9%, fibroma - 4%, neurofibroma - 3%, lipoma - 3%, lymphangioma - 3%, juvenile xanthogranuloma - 3%, granuloma annulare - 3%, mastocytomas - 2%, malignant tumor (usually sarcomas) - 1%.
  • This one is not a good story: this is a 3-year-old with the rapid onset and growth of a very hard nodular lesion that was violacious. A biopsy confirmed our worst fears… a lymphosarcoma.
  • And that is the end of this tale…MayFlower had a successful surgical removal and lived happily ever after… as far as I know.

The 20-month-old was playing on his own and accidentally struck the side of his face against a toy chest. 

Take a close look at the resulting lump. Is there anything about the lesion that would cause you to suspect a malignancy? What would be in your differential diagnosis for lumps and bumps in childhood? 

Follow the case in the slides above, provided by Dr. Jonathan Schneider, and put your visual diagnoistic skills to the test.


Suggested Reading

Kose D, Ciftci I, Harmankaya I, et al.  Pilomatrixoma in childhood. J Cancer Res Ther. 2014;10:549-51. doi: 10.4103/0973-1482.137918.

Kwon D, Grekov K, Krishnan M, Dyleski R. Characteristics of pilomatrixoma in children: a review of 137 patients. Int J Pediatr Otorhinolaryngol. 2014;78:1337-1341. doi: 10.1016/j.ijporl.2014.05.023. Epub 2014 Jun 2.

Nathwani S, Lam JM. Common lumps and bumps in children: A colour-coded differential. J Curr Clin Care. 2012;2.

Knight PJ, Reiner CB. Superficial lumps in children: what, when, and why? Pediatrics. 1983;72:147-153.

Chiaramonti A, Gilgor RS. Association of multiple pilomatrixomas and myotonic dystrophy. Arch Dermatol. 1978;114:1363-1365. doi:10.1001/archderm.1978.01640210058018.

Putnam TC. Lumps and bumps in children. Pediatr Rev. 1992;13:371-378.


Very interesting and very helpful, I am a general practitioner, and this case is very illustrative, thanks.

gloria @

Dr. Schneider, I rarely provide feedback to possible CME case reports, but I have to say this is one of the most informative bang-for-the-buck educational cases I've read. Thank you!
Ray Nejeres, M.D
Family Medicine

Raymond @

A belated thank you, Ray. I very rarely get feedback like yours. It is the "fuel"/inspiration that allows me to realize my goals in education. I strive to share what I have learned with my colleagues and to make our education not only accurate, but make it enjoyable to or learn. In "real life", my lectures have animations and sound effects to keep the audience awake.
Once again, I am most appreciative of your feedback


PGY - 42 (forever a student)

Jonathan @

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