Late onset congenital dermal melanocytosis – ‘Mongolian blue spots’ confused as child abuse: Are there more lessons to be learnt?

Abstract

Written and verbal consent was provided by the family for all aspects of this case including but not limited to treatment, investigations and publication. A 10-month-old male Asian infant (known here as Baby A) was brought to the emergency department of a tertiary hospital by his parents with skin discolouration interpreted as new bruising to his back and trunk. The parents described several falls onto a soft play mat while cruising along the edge of a couch over the days preceding presentation. No other history of trauma was offered. The infant had recently been in the care of members of the extended family for 3 days while his mother was hospitalised for an eye condition that compromised her vision. Baby A's mother noticed the new skin marks 4 days after she returned from hospital. No relevant past medical or family history and no history to suggest a coagulation disorder was obtained. The infant was developing normally and able to cruise but not walk independently. The parents described recent verbal conflict surrounding financial matters but there was no history of parental drug or alcohol misuse or family violence. Baby A was not known to protective services.Baby A was thriving, clean and well presented. There were no signs of neglect. Skin examination revealed a Mongolian blue spots (MBS) on Baby A's sacrum. His parents confirmed that this had been present since birth. Superior to the MBS were multiple areas of faint macular homogenous blue/green discolouration associated with multiple small erythematous marks suggestive of superficial abrasions (Fig. 1).To the right of the spine were two parallel linear areas of faint blue/purple discolouration. Two additional areas of faint blue/ purple discolouration were found on the left side of the trunk in the mid-axillary line overlying the lower ribs (Fig. 2). These areas were deemed by the child's parents and multiple medical staff to have the appearance of bruises. The rest of the skin examination and systemic examination revealed normal findings.Owing to the presence of unexplained bruising in an infant less than 1 year of age a full skeletal survey and nucleotide bone scan were performed to exclude or identify occult bony injury. An MRI brain was performed due to concerns from the treating medical team about irritability on a background of possible abusive injury. These investigations revealed no abnormalities. Ophthalmological examination revealed normal retina with no retinal haemorrhages. An extended coagulation profile revealed essentially normal results (mildly depressed factor 13 level).A suspected child abuse and neglect meeting was held, attended by the medical and forensic teams, the police and members of protective services. The opinion of the forensic paediatrician was that the appearance of the bruising was highly suggestive of inflicted injury. Plans were made to seek a protective application through the court; the child was discharged to the care of his parents with an undertaking to ensure his safety with the supervision of child protection servi...

Dermal Melanocytosis

“…These can be confused for bruises or child abuse. The features differentiating dermal melanocytosis from bruising include nontenderness to palpation, typically present at birth, and no changes over a short period (Prasad & Tully, 2017). Child abuse should be suspected when bruising is seen in children who are not mobile or infants, bruising is seen outside bony prominences, there are multiple bruises of uniform shape in clusters, or there are bruises with an imprint.…”