Visual Diagnosis: Large Mass with Ulceration over the Right Shoulder

Vanessa Amaral; Joyce Tong; Kam Ching Chow; Jorge Sales Marques

doi:10.1542/pir.2017-0073

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Vanessa Amaral, MD*
Joyce Tong, MD*
Kam Ching Chow, MD*
Jorge Sales Marques, MD*

^*Paediatrics Department, Centro Hospitalar Conde São Januário, Macau, China

AUTHOR DISCLOSURE
Drs Amaral, Tong, Chow, and Sales Marques have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A 4-month-old girl is referred to pediatric hematology outpatient services with an ulcerated erythematous mass over the right shoulder (Fig 1). A 2-mm macule was noted at 1 week of age, which has gradually increased in size, deepened in color, and protruded from the surface of the skin since 3 weeks of age. This lesion enlarged, developed central ulceration, and began oozing at 3 months of age. The patient is the older of twins born prematurely at 36 weeks and 4 days of gestation via cesarean delivery. Birth weight was 2,600 g. There is no significant medical or family history.

Figure 1.

Infantile hemangioma with ulceration over the right shoulder.

A physical examination reveals a well-appearing infant with an ill-defined, large, erythematous mass measuring 10 × 8 × 5 cm over the right shoulder superimposed with oozing from a central ulceration of 3 × 3.5 × 1 cm. No significant pulsation, bruits, or thrills are noted. On palpation the shoulder mass is firm, not movable or compressible. Ultrasonography of the lesion confirms the diagnosis.

Diagnosis

The diagnosis of infantile hemangioma (IH) is made based on clinical presentation, characteristic evolution, and physical examination findings. The diagnosis is subsequently supported by ultrasonography, which reveals a heterogeneous, hyperechogenic, 9 × 8.5 × 5-cm mass with considerable blood flow.

Discussion

IHs are common, benign vascular tumors affecting approximately 4% to 10% of infants and up to 30% of premature babies. IH occurs 4 times more frequently in females than in males. Studies have found that female sex, prematurity, low birth weight, multiple gestation, advanced maternal age, and white race are risk factors for the development …