A 7-year-old girl presents for evaluation of a pink, polypoid, 2 x 2-mm lesionon her inner lower lip, which has been present for several weeks. The child isasymptomatic and denies any trauma to the mouth.
A 7-year-old girl presents for evaluation of a pink, polypoid, 2 x 2-mm lesion on her inner lower lip, which has been present for several weeks. The child is asymptomatic and denies any trauma to the mouth. The lesion was excised under local anesthesia in the office. The initial diagnosis was capillary hemangioma. Does this diagnosis make sense-given that the lesion had only recently appeared and was not present at or shortly after the child's birth? What other diagnoses would you consider? Case 1:
The fact that the lesion had been present for only a few weeks ruled out the diagnosis of capillary hemangioma. A photograph of the gross lesion was sent to the pathologist who had made the initial diagnosis: review of the histology suggested a diagnosis of mucocele. Such lesions exhibit a pattern very similar to that seen in a capillary hemangioma: numerous small capillaries containing red blood cells and a stroma. In this girl's case, the overlying squamous mucosa of the lesion was largely intact, except for a small discontinuous site within which was a small amount of fibrin and a loose network of polyps, a few plasma cells, and lymphocytes. The pathologist believed that this section represented a peripheral margin of the mucocele: it closely simulates the pattern seen in a capillary hemangioma. This case underscores the importance of discussing the details of a case with the pathologist whenever the diagnosis does not fit the clinical presentation. Mucoceles occur as a result of duct obstruction or trauma to a duct with extravasation of fluid. This girl may have simply bitten her lip. In addition to excision, the lesion can also be treated with marsupialization. Case 2:
A 3-year-old boy presents with this dome-shaped lesion with crusted blood in the left periorbital area. The lesion has been present for 2 to 3 months. What is the most likely diagnosis?Case 2:
This lesion is a capillary hemangioma with focal surface ulceration containing fibrinous clot debris. The diagnosis is based on the clinical appearance of the lesion and can be confirmed histologically. The crusted ulceration is probably secondary to unrecognized trauma, but it may have resulted during spontaneous resolution of the hemangioma. Capillary hemangiomas (strawberry marks) are benign vascular growths. As mentioned in Case 1, they are usually present at or shortly after birth. It is rather unusual for a hemangioma to develop de novo in a 3-year-old child. Uncomplicated capillary hemangiomas usually involute spontaneously by early childhood and require no treatment. However, groin lesions that are subject to repeated trauma and bleeding may need to be excised. Facial lesions may be of cosmetic concern: they can be excised surgically or treated with oral and/or intralesional corticosteroids, subcutaneous interferon alfa-2a, or pulsed dye laser. This lesion was excised surgically in the office under local anesthesia Case 3: The lesion on this 6-month-old's left ear has been present since birth. It does not seem to be pruritic or painful. What is this lesion? Is treatment necessary?Case 3:
This is an acrochordon (skin tag). It requires no treatment. At first glance, this lesion may be mistaken for an accessory tragus; however, tragi typically do not occur on the ear pinna. This case is noteworthy because of the lesion's unusual location. Acrochordons usually develop on the face, neck, armpits, and groin.Case 4:
This 13-day-old infant has a red, cystic swelling at the right medial canthal area. At age 8 days, she had purulent conjunctivitis in the same eye along with an enlarged eyelid. Culture of the purulent material revealed α-hemolytic streptococcus. The conjunctivitis resolved with hot compresses followed by application of a 10% sulfacetamide ophthalmic ointment. Two days later, this painful swelling developed. What approach would you take?Case 4:
The infant was referred to an ophthalmologist who diagnosed nasolacrimal duct occlusion with secondary dacryocystitis. Dacryocystitis is uncommon in infants. In most cases, the infection clears spontaneously. When it does not, topical or systemic antibiotic therapy and decompression (by probing of the nasolacrimal duct and irrigation) may be necessary. Therapy with hot compresses and 10% sulfacetamide ophthalmic ointment every 4 hours was continued. The cystic swelling resolved the night after the patient was seen by the ophthalmologist, and it has not recurred.