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Mixed diagnoses – 10 cases (4 of 11)

For each of the ten cases, study the image(s) and then answer the questions. You can click on the image to view a larger version if required.

Each case should take approximately five minutes to complete. There is a list of suggested further reading material at the end of the quiz.

When you finish the quiz, you can download a certificate.

Case 4

A red nodule has developed on the scalp of a 2-month old baby over the last few weeks. It was not present at birth.

This is a superficial haemangioma, commonly known as a strawberry naevus. Acquired proliferative haemangiomas affect 10% infants, arising more frequently in females (ratio 3:1) and pre-term infants (22% of those weighing under 1000g). They are multiple in 20% of cases, 60% arising on the head and neck. They grow rapidly because of neonatal angiogenic growth factors, starting within a few months of life reaching a peak at about a year.

Regular review. Most haemangiomas do not require treatment. Nearly all haemangiomas undergo complete involution by age 10-12 years. Minor scarring, telangiectasia or excess fibrofatty tissue may remain.

Apart from referring to a specialist for parental reassurance, the following features of haemangiomas may necessitate intervention: uncontrolled bleeding or ulceration; severe aesthetic deformity or residual disfigurement; functional complications e.g. lesion occluding lip, eyelid, nose; platelet trapping coagulopathy (Kasabach-Merritt syndrome) with very large haemangiomas. The choice of specialist may depend on where the lesion is located.

The following measures are rarely used: systemic steroids to control proliferation; flash lamp pulsed dye laser to lighten the colour; surgical excision, most often to remove residual redundant tissue. Recombinant interferon alfa-2a is no longer recommended because of serious complications including spastic diplegia.

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