Deep Tissue Hematomas—What Are We Forgetting?

Abstract

An 8-year-old boy, diagnosed with autism, was referred to our department from another hospital due to profound normocytic anemia, without manifest bleeding. Problems started 4 months prior to admission, when he refused to stand on his feet after a minor fall, although an x-ray of his legs excluded fractures and other significant bone pathology. Initially, the refusal to walk was explained by a psychological reaction to fall. However, in the following period his condition progressively worsened; he stopped communicating, became incontinent, apathetic, inappetent, and generally very dissatisfied. Finally, he was hospitalized in critical condition and received urgent erythrocyte transfusion (Hb 4.3 g/dL).On admission, he was in poor general condition, agitated, tachycardic, and pale. Although the patient's body mass index (BMI) was 15.4 kg/m 2 (body height 130 cm, body weight 26 kg), placing the BMI-for-age at the 40th percentile, he seemed severely malnourished, he was sarcopenic and edematous. He had a diffuse perifollicular rash, gingival swelling, multiple dental caries, as well as signs of nutritive deficiency on his nails-leukonychia and Beau's lines. In addition, the patient presented with massive swelling of the left thigh (Figure 1). The skin above the swelling was tense and warm, while all arterial pulsations on the distal extremities were well palpable. Initial laboratory findings revealed normocytic anemia with reticulocytosis (post-transfusion Hb was 10.3 g/dL), severe hypoalbuminemia, hyponatremia, and elevated d-dimer levels. We conducted a Doppler ultrasound examination of both of his legs and abdomen, which excluded venous thrombosis, but detected 2 inhomogeneous soft tissue changes, one along the entire length of the left femur, from the trochanter minor to the femoral condyles, and the other along the left iliac bone. To clarify the etiology of those structures, the patient underwent a whole-body magnetic resonance imaging (MRI) scan which revealed multiple soft tissue changes (skin, subcutaneous mass,

Cold and Constipated: Beyond Hypothyroidism

“…Many case reports have been recently written about the modern occurrences of scurvy, especially in children and picky eaters, and those with diseases of malabsorption such as celiac disease, or on restrictive diets. Many patients present with non-specific symptoms, from anorexia [17] and fatigue, to neurologic deficits [18] with or without the classic dermatologic and hematologic findings, often delaying diagnosis and treatment [19][20][21][22][23][24]. Other patients have presented with dramatic dermatologic findings, masquerading as a deep soft tissue infection [25].…”