Discolored Buttocks: Abuse or Not?

Introduction: Bruising is the most common evident injury in children who have been physically abused. Moreover, certain locations of bruising are more consistent with physical abuse. For example, in children younger than 4 years, and back, buttocks, forearm, foot and abdomen are rarely bruised from day to day activities. Here we discuss a 7-month old child who presented with bruised buttocks and was diagnosed with Acute hemorrhagic edema of infancy (AHEI), though physical abuse was a leading differential diagnosis.

Case Description: K.H. is a 7-month-old male who presented to our pediatric emergency room with bruised buttocks. The mother reported that she first noticed the bruising while giving the child a bath and reported that bruising appeared to have spread down the thighs bilaterally. On further questioning, the mother states that the child had fallen asleep on a hard-plastic swing, had a low height fall onto the floor from the family sofa 3 days prior, and had been increasingly fussy. Incidentally, review of child’s records, found to have had another ED visit for being dropped by older sibling at 4 months of age, which was at that time was found to have a benign clinical exam.

Discussion: Acute hemorrhagic edema of infancy (AHEI) is a rare cutaneous illness that affects children between the ages of 4 months and 2 years of age and is classically thought of as a purely cutaneous form of Henloch-Schonlein Purpura given its luekocytoclastic vasculitis properties. AHEI has classically been characterized with a triad fever, purpuric lesions and edema. This can yield the physician to be faced with a wide differential, however in the absence of a fever and often an unclear history, non-accidental trauma must also be considered and can often pose a diagnostic challenge given that bruising patterns associated with AHEI are more consistent with physical abuse rather than routine childhood activities.

Conclusion: Given the vague history provided by the mother and previous emergency room visit, our child abuse service was consulted and agreed a non-accidental trauma work up was warranted. The work up was further justified by the utilization of the TEN-4-FACESp decision making tool. . This work up included labs, a computerized tomography scan of the child’s head, a skeletal survey and ophthalmological evaluation. The work up was negative except for an elevated D-dimer, which would be expected with the presence of bruising seen. Consequential, be exclusion of other differentials, most notably physical abuse, the diagnosis of AHEI was made.