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Australasian Journal of Dermatology (2001) 42, 207–210
Subcutaneous fat necrosis of the newborn following hypothermia and complicated by pain and hypercalcaemia Todd P Wiadrowski and Gillian Marshman
Flinders Medical Centre, Bedford Park, South Australia, Australia history of the condition is for resolution without scarring. Themost common complication of SCFN is hypercalcaemia, which has been associated with neonatal death.2 We describe A female infant was delivered at term with compli- a child with an overlapping clinical presentation following cations of severe meconium aspiration and birth medically induced hypothermia to treat birth asphyxia. In this asphyxia. Surface cooling was performed in the first case, the initial clinical features of cold panniculitis progressed 24 hours as part of the management of her birth to those of SCFN, both clinically and histologically. This asphyxia. Woody erythema was noted at 24 hours, patient's case was further complicated by pain and hypercal- followed by the formation of red–purple nodules on the 6th day. Clinical findings in the first 24 hours were sug-gestive of cold panniculitis. However, clinical and his- CASE REPORT
tological findings progressed to be in keeping with thediagnosis of subcutaneous fat necrosis of the newborn A female infant was born at term weighing 4350 g. Standard (SCFN). Furthermore, the immediate postnatal period maternal prenatal screens revealed no significant abnormal- was complicated by pain resistant to treatment with ities (haemoglobin, group and screen, glucose tolerance test, opiates. Asymptomatic hypercalcaemia was noted on rubella serology, syphilis serology, hepatitis B surface anti- periodic testing at 7 weeks and treated by rehydration, gen, hepatitis C serology, HIV serology and midstream urine diuretics, prednisolone, etidronate and a low-calcium specimen). The mother was noted to have mild hypertension and -vitamin D diet. A review of the clinical and histo- with associated oedema and albuminuria in the third logical findings of the relevant panniculitides occurring trimester. No medications were taken during the pregnancy.
in the postnatal period is presented, as well as a review Table 1 details the significant events after delivery and over of the treatment of hypercalcaemia in SCFN.
the ensuing months. During the first 24 hours, the child was Key words: cold panniculitis, corticosteroids, etidro-
noted to be hypotensive with cardiogenic shock requiring nate, infants, opiates, panniculitis.
dopamine, had a pneumothorax, acute renal failure and amild disseminated intravascular coagulation. Within the firsthours of life, a decision was made for paralysis and sedation,with her core temperature kept between 32 and 33°C to treat her birth asphyxia. Hypothermia was achieved with the useof ice packs applied to the skin and turning off the overhead Subcutaneous fat necrosis of the newborn (SCFN) is a transi- heating lamps. Her temperature was monitored via a rectal ent panniculitis of neonates typically presenting within the probe. This temperature was held for 24 hours, then raised first 6 weeks of life. Most reported cases involve infants at full to 35°C and then 37°C over a 3 day period.
term or post-dates and of normal size for dates, but often with Approximately 24 hours post-delivery, a pink woody oede- a history of birth asphyxia, meconium aspiration, cyanosis, matous change was noted on the infant's thighs and back, as seizures and hypothermia. An association with maternal well as petechiae on the right ankle. This progressively wors- diabetes and pre-eclampsia has been reported.1 The natural ened over the ensuing 4 days and the buttocks were noted tobe exquisitely tender to touch with grimacing and shrill cry.
Plaques and nodules formed within these backgroundchanges at 6 days of age. A clinical diagnosis of SCFN was Correspondence: Dr G Marshman, Dermatology Unit, Department made (Fig. 1).
of Internal Medicine, Flinders Medical Centre, Flinders Drive, Bedford Histology revealed an acute panniculitis with frank fat Park, SA 5042, Australia.
necrosis and needle-like clefts (Fig. 2), which confirmed the Todd P Wiadrowski, BM, BS. Gillian Marshman, FACD.
Submitted 12 September 2000; accepted 6 February 2001.
clinical diagnosis of SCFN.

TP Wiadrowski and G Marshman Purple nodules formed on erythematous and oedematous Skin biopsy from sacral nodule demonstrating radially buttock skin at seven days postnatally.
arranged needle shaped clefts at seven days postnatally (H&E).
Pain was poorly controlled by morphine. Due to continued was also suggested that etidronate should not be given difficulties with analgesia and the formation of new plaques within 2 hours of milk feeds because calcium–drug binding and nodules, prednisolone was added at a dose of 1 mg/kg per may occur and reduce absorption. Cisapride (1 mg, orally day on day 34. This led to a definite improvement in pain t.d.s.) had already been commenced for the treatment of control and subjective improvement in the intensity of the the infant's GOR and this was continued while etidronate was being administered. Calcium, parathyroid hormone and Weekly measurements of serum calcium detected hyper- 1,25(OH)2-vitamin D3 levels were 3.49 mmol/L, 0.4 pmol/L calcaemia at a corrected level of 3.74 mmol/L (normal (normal range 1.1–6.9 pmol/L) and 55 pmol/L (normal range range 2.20–2.75 mmol/L) 49 days after delivery. The infant's 50–160 pmol/L), respectively. These levels were taken at the weight at this time was 4910 g. Intravenous access was same time as the etidronate was started and it should be noted particularly difficult to attain in this infant and, therefore, that the infant had been taking prednisolone for 19 days prior initial treatment was with oral fluids, frusemide (8 mg, orally to this. A low-calcium and -vitamin D formula (Locasol) was b.d.) and spironolactone (5 mg, orally b.d.). Prednisolone was commenced on day 54 and frusemide and spironolactone were being administered at a dose of 5 mg on alternate days when ceased. Etidronate was continued for a total of 8 days treat- hypercalcaemia was detected and this was then increased to ment. At this time, calcium levels had normalized.
5 mg, daily.
Prednisolone was weaned over the ensuing 21 days because After 4 days treatment, as described above, calcium levels the infant's pain had settled.
were stable, but without significant decline. Etidronate Locasol was continued for 7 months and, when the was started at an oral dose of 25 mg, twice daily. Due to the child was weaned onto solids, a diet low in calcium was irritant nature of etidronate and the patient's underlying used initially. This diet consisted of fruit, vegetables, meat, gastro-oesophageal reflux (GOR), the infant was nursed in cereals, such as rolled oats and semolina, and avoidance of an upright position for 30 min following administration. It dairy products. It was noted that some cereals, in particular Time-course of presented case Mid-cavity forceps delivery at term, thin meconium, cord pH 6.97 Apgar score 5, first spontaneous gasp followed this Endotracheal oxygen, adrenaline, hypothermia-induced paralysis and sedation Woody pink oedematous change on thighs and back, petechiae of right ankle Buttocks noted to be tender to touch Nodules arise within previously erythematous and oedematous areas Biopsy taken; histology shows needle-shaped clefts in lipocytes and fat necrosis Cisapride started Prednisolone added at 1 mg/kg per day with subsequent improvement in pain relief Hypercalcaemia 3.74 mmol/L corrected, treatment commenced with oral rehydration, frusemide and spironolactone, prednisolone dose increased back to 1 mg/kg per day Hypercalcaemia 3.49 mmol/L corrected, etidronate 25 mg twice daily; normal vitamin D level Locasol added, frusemide and spironolactone ceased Etidronate ceased Prednisolone ceased Resolution of most nodules Subcutaneous fat necrosis of the newborn baby rice cereals, are fortified with calcium and should be channel blocker have not been highlighted. In our case, the avoided. A diet free of restrictions was commenced after infant's lesions were noted to be painful as nodules began to arise. Cold panniculitis has been described as having tender The infant continued to display nodules, predominantly on nodules in adults6 and it is not unreasonable to expect these the proximal extremities and back, with slow resolution of lesions may be tender in infants. Morphine, at doses of 1–2 mg most of these lesions by 6 months. At 9 months, the firm four times a day, was administered without complete pain con- nodules that were present at her previous visit had altered trol. It was decided to add prednisolone at a dose of 1 mg/kg little. Magnetic resonance imaging (MRI) was performed.
per day. This had a synergistic effect with morphine, giving Calcification was not present. The MRI appearances were of complete pain control with doses of morphine that were pre- septate lesions composed of soft tissue and lipid. The nodules viously insufficient. There was also some subjective improve- are stable and asymptomatic and further biopsy has not been ment in the erythema overlying the nodules as well as a decrease in nodule size. We believe that the use of predniso-lone should be strongly considered over the short-term in cases complicated by painful lesions. Evidence is lacking as to whether this changes the overall disease course or Subcutaneous fat necrosis of the newborn is an uncommon transient panniculitis seen in term to post-term neonates that Hypercalcaemia complicating SCFN is well recognized, but usually resolves without scarring. Lesions often develop on the pathogenesis is yet to be fully determined. Hypercalcaemia skin that initially appears oedematous prior to the formation occurs between 2 and 16 weeks, most commonly at 6–7 of red–purple nodules and plaques.1,3 The nodular lesions of weeks.7 Clinically, the most common feature is failure to thrive SCFN may present during the first 6 weeks, with one study (90%), followed by fever, vomiting, feeding difficulties, reporting 45% of lesions arising in the first week of life.4 A dif- irritability and listlessness. Mortality from hypercalcaemia ferential diagnosis would include sclerema neonatorum (SN) complicating SCFN has been estimated at 15%.2 Because the and cold panniculitis, as outlined in Table 2.
child may have been discharged by the time these features Our patient was noted to have pink woody oedematous skin arise, education of the parents to recognize these symptoms on the thighs and back 24 hours after delivery. The distribution and report this to the managing physician is essential. To the of these areas corresponded to the areas of application of the best of our knowledge there are no specific guidelines for ice packs used to lower the child's core temperature.
routine monitoring of serum calcium levels in these cases. For Therefore, these features could be in keeping with cold pan- our patient, it was decided to perform weekly investigations niculitis. However, at 6 days post-delivery, nodules were noted of serum calcium and albumin levels until 16 weeks of age.
that steadily increased in size. These nodules were biopsied Once a diagnosis of hypercalcaemia has been made, treat- and demonstrated features in keeping with SCFN. Therefore, ment options considered are outlined in Table 3.11 It is nec- while we have clinical and histological evidence of SCFN, the essary to stress the importance of adequate hydration in the lack of a biopsy specimen of the earliest lesion allows us only treatment of hypercalcaemia. Rehydration with a resultant to speculate that, on clinical grounds, the infant either had an increase in intravascular volume will increase glomerular atypical presentation of SCFN or that this is a case of cold filtration rate and increase renal calcium clearance.12 panniculitis progressing to SCFN.
Loop diuretics are used to achieve increased calcium Painful lesions that proved to be difficult to control with excretion by inhibiting calcium reabsorption and preventing opiate analgesia complicated the course of our case. An infant volume overload secondary to the rehydration. Thiazide with painful SCFN requiring the use of morphine has been diuretics should not be used because they increase distal reported following the maternal use of amlodipine.10 Painful tubular reabsorption of calcium and, therefore, may aggravate lesions in cases of SCFN without the maternal use of a calcium the process.
Differential diagnosis of subcutaneous fat necrosis of the newborn1,3,5–9 Subcutaneous fat necrosis Cold panniculitis Sclerema neonatorum Full term/post-dates Predisposing factors  Maternal diabetes, hypertension No maternal factors No maternal factors  Birth asphyxia, meconium aspiration, cyanosis, Cold stress Uneventful delivery seizures, hypothermia Within 72 hours of exposure Within the first week Red, blue nodules on trunk, buttock, arms, face, Red, blue induration  plaques Diffuse yellow–white  nodules, sparing the genitalia, palms and soles Fat necrosis, foreign body giant cells, lymphocytic Lobular panniculitis, mixed Needle-shaped clefts in infiltrate, radially arranged needle-shaped clefts infiltrate, no needle-shaped lipocytes, nil to mild inflammatory infiltrate or fatnecrosis, septa widened by oedema Generally very good; hypercalcaemia carries a 15% Excellent Poor, 75% mortality TP Wiadrowski and G Marshman Management of an infant with subcutaneous fat necrosis of the newborn11–14 Education of parents regarding disease and symptoms and signs of hypercalcaemia (failure to thrive, fever, vomiting,feeding difficulties, irritability and listlessness); protect areas of panniculitis from trauma plus dressings for ulceration Weekly serum calcium and albumin levels to 16 weeks of age; rehydration, dietary vitamin D and calcium restriction,frusemide and prednisolone; consider etidronate if other measures fail Opiates, prednisolone Prednisolone is used in the treatment of hypercalcaemia, failed. Normal serum calcium levels were subsequently main- particularly in cases associated with haematogenous malig- tained with dietary measures.
nancy or cases of 1,25(OH)2-vitamin D3 excess, such assarcoidosis. It has been suggested that the pathogenesis ofhypercalcaemia in SCFN may be similar to that of sarcoidosis and, therefore, prednisolone would have a role in its treatment.
1. Fretzin DF, Arias AM. Sclerema neonatorum and subcutaneous In our case, prednisolone was administered for 15 days prior fat necrosis of the newborn. Pediatr. Dermatol. 1987; 4: 112–22.
to the onset of hypercalcaemia. This may suggest that either 2. Norwood Galloway A, Lebwohl M, Phelps RG, Raucher H.
the dose was inadequate, that prednisolone alone is unable Subcutaneous fat necrosis of the newborn with hypercalcemia. to treat hypercalcaemia associated with SCFN or that J. Am. Acad. Dermatol. 1987; 16: 435–9.
the pathogenesis is unrelated or only partially related to the 3. Atherton DJ. The neonate. In: Champion RH, Burton JL, Burns production of 1,25(OH) DA, Breathnach SM (eds). Textbook of Dermatology, Vol. 1, 6th edn.
2-vitamin D3. We can only comment Oxford: Blackwell Science, 1998; 449–518.
that, in our case, hypercalcaemia occurred despite the use of 4. Burden AD, Krafchik BR. Subcutaneous fat necrosis of the new- prednisolone and that vitamin D3 levels, when taken, were born: A review of 11 cases. Pediatr. Dermatol. 1999; 16: 384–7.
5. Black MM, Cunliffe WJ. Subcutaneous fat. In: Champion RH, Etidronate is a member of the bisphosphonate group of Burton JL, Burns DA, Breathnach SM (eds). Textbook of drugs that are known to decrease bone resorption. Etidronate Dermatology, Vol. 3, 6th edn. Oxford: Blackwell Science, 1998; has been reported to be successful in the management hyper- 6. Bondi EE, Margolis DJ, Lazarus GS. Panniculitis. In: Freedberg calcaemia associated with SCFN13 and, due to the resistant IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, nature of the hypercalcaemia to first-line treatments described Fitzpatrick TB (eds). Fitzpatrick's Dermatology in General above, this was embarked upon. The dose used was 5 mg/kg, Medicine, Vol. 1, 5th edn. New York: McGraw-Hill, 1999; 1275–89.
which was in keeping with the previous report. The use of 7. Hicks MJ, Levy ML, Alexander J, Flaitz CM. Subcutaneous fat bisphosphonates, while effective in our case, should not be necrosis of the newborn and hypercalcemia: Case report and embarked on lightly because their effect on bone production, review of the literature. Pediatr. Dermatol. 1993; 10: 271–6.
8. Lewis A, Cowen P, Rodda C, Dyall Smith D. Subcutaneous fat growth plates and mineralization is yet to be clarified.14 necrosis of the newborn complicated by hypercalcaemia and However, once etidronate was started, calcium levels fell to thrombocytopenia. Australas. J. Dermatol. 1992; 33: 141–4.
normal, at which time etidronate was ceased.
9. Weedon D. Panniculitis. In: Skin Pathology. Edinburgh: Churchill A low-calcium and -vitamin D3 formula should also be Livingstone, 1997; 441–56.
added at the earliest possible stage and would optimally 10. Rosbotham JL, Johnson A, Haque KN, Holden CA. Painful sub- have been best used in association with the initial treatments cutaneous fat necrosis of the newborn associated with intra- as described above if it had been readily available at our partum use of a calcium channel blocker. Clin. Exp. Dermatol.
1998; 23: 19–21.
11. Ghirri P, Bottone U, Coccoli L, Bernardini M, Vuerich M, Cuttano In conclusion, we present a case with early clinical features A, Riparbelli C, Pellegrinetti G, Boldrini A. Symptomatic hyper- in keeping with cold panniculitis, but an overall clinical and calcemia in the first months of life: Calcium-regulating hormones histological picture of SCFN. This case was unusual in that it and treatment. J. Endocrinol. Invest. 1999; 22: 349–53.
was complicated by significant pain in the infant only partially 12. Wood AJJ. Management of acute hypercalcaemia. N. Engl. J. Med. controlled with opiate anaesthesia. Oral prednisolone 1992; 326: 1196–203.
13. Rice AM, Rivkees SA. Etidronate therapy for hypercalcemia in appeared to act synergistically with morphine to control this subcutaneous fat necrosis of the newborn. J. Pediatr. 1999; 134:
infant's pain and should be considered for use in similar cases.
In this case, etidronate was used with success over an 8 day 14. Shoemaker LR. Expanding role of bisphosphonate therapy in course to control hypercalcaemia when first-line treatment children. J. Pediatr. 1999; 134: 264–7.

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