This month’s column begins with a case report. A full-term girl was born via cesarian delivery due to a failure to descend and complex presentation. Maternal history was not significant for any illnesses; this pregnancy was complicated by polyhydramnios. The author’s team was consulted by the newborn nursery pediatrician after multiple lesions were found immediately after delivery. The largest, a 3 cm × 1 cm dusky purpuric retiform patch, was noted over the left medial ankle area. The peri-lesion rim was erythematous, and the foot in general was swollen compared with the right foot. Two (2) tiny vesicles were noted within the patch. Three (3) smaller purpuric lesions were appreciated over the dorsal lateral ankle area and heel (Figure 1). Another erythematous, irregularly shaped, angulated blanchable patch was appreciated over the left parietal scalp area (Figure 2). No peri-wound edema or erythema were noted.
No discomfort was appreciated on palpation. The patient was admitted to the neonatal intensive care unit, where immediate management included application of nitroglycerine ointment 2% (Savage Laboratories, Berkeley, CA) twice a day to the left foot lesion, alternating with warm compresses (the team’s standard management of potential ischemic injury), and observation of the head lesion.
Given the differential diagnoses of ischemia, thrombosis (vasculopathy/hypercoagulopathy), congenital vascular malformation, or pressure injury (specifically deep tissue injury, based on the physical examination findings) hematology and dermatology services were consulted. The following studies were completed:
Coagulopathy work-up (complete blood count, coagulation, D-dimer, fibrinogen, protein C and S, antithrombin 3, factor V Leiden gene mutation, beta-2 glycoprotein, and anti-cardiolipin antibody): normal
Ultrasound of the area with arterial and venous doppler studies: normal flow, no thrombi
Point-of-care ultrasound: this study showed the break in the normal subcutaneous fat tissue and hypoechoic changes underlying injured area of the left ankle.
One of the vesicles within the lesion progressed to develop a blister within 24 hours after presentation (Figure 3). The blister was punctured through and through with a sterile needle to avoid tension and worsening skin injury, but without complete deroofing to act as a natural biologic dressing. Because the ultrasound reveled normal vascular flow, nitroglycerine ointment was discontinued. Surfactant-based wound and burn dressing (PluroGel; Medline, Northfield, IL, USA) was added on day 2 for cell salvage1 and moist healing as the injured superficial skin layer started to desquamate. On day 3, point-of-care ultrasound captured a deep tissue injury path toward the epidermis. The smaller lesions over the left medial ankle area and the head lesion were getting smaller, without skin breakdown.
On day 4, the patient was discharged. The parents were comfortable with applying surfactant-based gel once a day to the ankle area, covered by silicon dressing. The patient was seen 1 week later. At that time, the larger ankle lesion was almost healed; the head deep tissue injury and the smaller ankle deep tissue injury were completely healed.