What Caused This 7-Year-Old Girl’s Facial Bruise?

Authors:

Reesa Lendry
Medical Student, University of Florida College of Medicine, Gainesville, Florida

Maria N. Kelly, MD
Associate Professor, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida

Rachel M. Coleman, MD
Assistant Professor, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida

Carolyn G. Carter, MD
Associate Professor, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida

Citation:

Lendry R, Kelly MN, Coleman RM, Carter CG. What caused this 7-year-old girl’s facial bruise? [published online January 26, 2018]. Consultant for Pediatricians.

A 7-year-old girl with a history of asthma and allergic rhinitis presented to her primary care physician (PCP) for a follow-up visit after an emergency department (ED) visit the previous day for a barky cough.

History. The day prior to presenting to our clinic, the patient had experienced a barky cough, watery eyes, and a runny nose. She had used albuterol (delivered via metered-dose inhaler with spacer) without improvement of her cough. For that reason, she had been taken to the ED.

In the ED, there were concerns for croup as opposed to an asthma exacerbation. For that reason, she had been given 14 mg of oral dexamethasone (0.6 mg/kg ordered with maximum dose of 14 mg, based on the patient’s weight of 33.3 kg). After a few hours, the patient had reported decreased cough and more-comfortable breathing. No albuterol had been administered in the ED. She had been advised to follow up with her PCP the next day.

In our clinic the next day, the patient and her mother had no concerns related to her breathing or coughing. However, the family had noticed the appearance of a new bruise between the child’s nose and mouth following her ED visit.

The bruise was localized to her face and was not tender. There was no known history of trauma or injury. The patient had had no fevers, night sweats, pallor, easy or prolonged bleeding, or unusual bruising in other areas.

Physical examination. Findings of a complete review of systems were negative except for the bruise. There was no family history of bleeding disorders.

On physical examination, the patient had a temperature of 37.1°C and weighed 33.3 kg (91st percentile). She appeared healthy and well developed and was in no acute distress. Head, eyes, ears, nose, and throat examination findings were normal, as were cardiovascular, lung, and abdominal examination findings.

On examination of her skin, she had purplish bruising on her philtrum, upper lip, sides of her mouth, and just below her lower lip in a circular pattern (Figure). The central portion of the lower lip was spared. The remainder of skin examination findings were unremarkable, with no other bruising, petechiae, or purpura noted.

Based on the patient’s history and examination findings, what explains the girl’s bruise?

1. Traumatic injury
2. Self-mutilation
3. Suction-induced bruise
4. Child abuse

Answer on next page.