Update on juvenile xanthogranuloma: unusual cutaneous and systemic variants

Intralesional glucocorticoid treatment of an isolated intracranial juvenile xanthogranuloma: a case report

Juvenile xanthogranuloma is a type of non-Langerhans cell histiocytic process that appears primarily in children and is described as a benign lesion. Although they typically present as a cutaneous lesion, it can also present in other areas including within the central nervous system. We report a 6-month-old infant who presented with seizure-like activity who was found to have a single intracranial mass within the right temporal area on magnetic resonance imaging of the head. The mass was biopsied and pathologically identified as a juvenile xanthogranuloma. In order to avoid the morbidity associated with a gross total resection, an intralesional steroid injection was utilized for treatment which our patient tolerated well. Intralesional steroid injection for the treatment of a symptomatic isolated intracranial juvenile xanthogranuloma has not been described but was successful for our patient.

Symmetrical Facial Giant Plaque-Type Juvenile Xanthogranuloma: Case Report and Review of the Literature

Juvenile xanthogranuloma (JXG) is the most common type of non-Langerhans cell histiocytosis. JXG is a rare benign tumor, which may be present at birth or develop later. The classical form of JXG is characterized by a red-yellowish benign papule or nodule with predilection sites on the head, neck, and trunk, although lesions can appear on extremities or extracutaneous sites. In most cases there is only one lesion, whereas numerous papules or nodules may occur. Special forms of JXG such as mixed, giant, subcutaneous, eruptive, clustered, and plaque-like have been reported and associations between JXG and systemic diseases have been made. Diagnosis mainly relies on the clinical appearance, and histology usually can confirm the disease. Here we present a very rare case of symmetrical giant facial plaque-type juvenile xanthogranuloma (SGFP-JXG) and compare it with classical JXG, variations of JXG, and discuss the differential diagnosis. A 4-year-old Caucasian female presented with plaque-like lesions composed of yellowish confluent papules on both the cheeks. The histological evaluation revealed a histiocytic lesion with a formation of Touton giant cells and immunohistochemistry results confirmed the diagnosis of the SGFP-JXG. In comparison to classical JXG, the onset of SGFP-JXG sometimes occurs later and the spontaneous resolution period may be prolonged. No associated diseases and no systemic involvements were observed. Histopathology is required to differentiate this form of JXG from other histiocytosis. To the best of our knowledge, only four cases of SGFP-JXG have been reported in the literature so far.

Juvenile Xanthogranuloma on the Upper Lip

We treated a patient with juvenile xanthogranuloma on the upper lip. A yellow, elastic, hard tumor on the upper lip was evident from birth, which gradually increased in size. The patient was examined at our department at the age of 7 months, at which time the mass extended from the upper lip to the nasal cavity and measured approximately 1 cm. There was a risk that the mass might obstruct the nasal cavity, and an incisional biopsy was conducted to obtain a definitive diagnosis. In histopathological testing, the patient was diagnosed with a juvenile xanthogranuloma. Part of the mass still remains on the upper lip, but has not increased in size during postoperative monitoring. Juvenile xanthogranuloma on the upper lip is extremely rare, and to the best of our knowledge, this is only the fourth case to be reported in the plastic surgery literature in English. In most cases, juvenile xanthogranuloma regresses spontaneously, and unnecessary surgery is to be avoided. The possibility of juvenile xanthogranuloma should always be considered for masses that increase in size in infants and young children, and it is important to reach a definitive diagnosis by skin biopsy.

Multiple Xanthogranulomas in an Adult Patient with Myelodysplastic Syndrome

Adult multiple xanthogranuloma (XG) is a rare late-onset variant of juvenile XG. It is characterized by the appearance of papules or nodules located preferably on the trunk. A case of a 54-year-old man with myelodysplastic syndrome is presented as a history of interest, who consulted due to the appearance of multiple brownish papules distributed mainly in the trunk. So far, there are only 22 cases of this clinical form reported in the literature, 9 of them associated with malignant hematological processes. We highlight the importance of this entity as a possible cutaneous marker of blood dyscrasias.

Juvenile Xanthogranuloma: An Entity With a Wide Clinical Spectrum

Juvenile xanthogranulomas (JXGs) are rare, benign lesions that belong to the large group of non-Langerhans cell histiocytoses. JXG presents with 1 or more erythematous or yellowish nodules that are usually located on the head or neck. Most JXG lesions are congenital or appear during the first year of life. Extracutaneous involvement is rare, but the literature traditionally suggests investigating the possibility of ocular compromise. JXG is mainly a clinical diagnosis, but a skin biopsy may sometimes be needed for confirmation. JXGs on the skin are self-limiting and usually do not require treatment. This review describes the clinical and therapeutic aspects of JXG, emphasizing available evidence and the diagnosis of extracutaneous involvement.

Juvenile xanthogranulomas: Examining single, multiple, and extracutaneous presentations

BACKGROUND

Juvenile xanthogranuloma (JXG) is a non-Langerhans cell histiocytosis characterized by yellowish papules in the skin. JXGs most often occur in infancy or early childhood and are typically solitary and asymptomatic, often regressing after several years. While JXGs predominantly occur on the skin, extracutaneous JXGs also exist.

AIMS

In this paper, we review the literature on single, multiple, and visceral JXGs and provide recommendations on monitoring and work-up.

MATERIALS & METHODS

A literature review was conducted with the PubMed database using selective search terms for single, multiple, ocular, and visceral lesions as well as NF1/JMML.

RESULTS / DISCUSSION

JXG is typically a self-limited disorder if lesions are cutaneous and singular. While rare, JXGs may manifest as multiple and extracutaneous lesions. Further screening and referral to specialists may be warranted in these cases based on age and extent of involvement.

CONCLUSION

Our review demonstrates common presentations of single, multiple, and extracutaneous lesions in addition to those that occur with NF1 and JMML. We suggest patients be evaluated on a case-by-case basis by a dermatologist and referred to specialists as appropriate.

Therapy Response in a Pediatric Patient With Extracutaneous Juvenile Xanthogranuloma Monitored by FDG PET/CT

Juvenile xanthogranuloma, a rare type of non-Langerhans cell histiocytosis, generally manifests as widespread skin lesions, which is often self-limited. However, when other organs are involved, its outcome can be unfavorable, and there is no clearly defined consensus regarding what is the best imaging modality in monitoring the therapy. We report here findings of a series of FDG PET/CT scans during the course of clofarabine therapy in a 12-year-old girl with extracutaneous juvenile xanthogranuloma.

Infantile Myofibroma Presenting as a Large Ulcerative Nodule in a Newborn

The differential diagnosis of a congenital cutaneous vascular-appearing mass in a newborn is broad and includes both benign and malignant tumors. We report the case of a newborn who presented with an erythematous exophytic skin nodule on the right upper leg. Excision was performed due to ulceration, concern for bleeding, and for diagnosis. Pathology revealed the mass to be an infantile myofibroma. This case highlights the importance of considering a broad differential diagnosis in a newborn with a cutaneous mass. While history, physical exam, and imaging can help diagnose some cases, a biopsy or excision is often needed to distinguish benign lesions from more concerning lesions.

Infantile systemic juvenile xanthogranuloma case with massive liver infiltration

Infantile systemic juvenile xanthogranuloma (ISJXG) is an uncommon form of juvenile xanthogranuloma, a non-Langerhans cell proliferation of infancy and early childhood. In a small percentage of patients, the visceral involvement—most commonly to the central nervous system, liver, spleen, or lungs—may be associated with severe morbidity, and eventually fatal outcome. Here we describe the clinical and pathological findings of a 28-day-old girl with ISJXG who died with respiratory distress syndrome. She had few cutaneous lesions but massive liver and spleen infiltration; other affected organs were multiple lymph nodes, thoracic parasympathetic nodule, pleura, pancreas, and kidneys. Additional findings were mild pulmonary hypoplasia and bacteremia. Immunohistochemistry on fixed tissues is the standard for diagnosis. Immunophenotype cells express CD14, CD68, CD163, Factor XIIIa, Stabilin-1, and fascin; S100 was positive in less than 20% of the cases; CD1a and langerin were negative. No consistent cytogenetic or molecular genetic defect has been identified. This case demonstrates that the autopsy is a handy tool, because hepatic infiltration, which was not considered clinically, determined a restrictive respiratory impairment. In our opinion, this was the direct cause of death.

JUVENILE XANTHOGRANULOMA: A CASE REPORT

Objective:

To report a rate case of Juvenile xanthogranuloma in a newborn infant.

Case description:

We present the case of a 31-week preterm newborn with multiple skin lesions whose clinical, histological and immunohistochemical findings allowed the diagnosis of juvenile xanthogranuloma. Currently, the patient has nine months-old, and there is no aggravation of the skin lesions or evidence of extra-cutaneous involvement, particularly ophthalmic.

Comments:

Juvenile xanthogranuloma is a rare and benign condition, included in the vast group of non-Langerhans histiocytosis. It typically occurs in the pediatric age and may have a neonatal presentation. It affects predominantly the skin, in the form of papules or yellow and/or erythematous nodules and could be asymptomatic, multiple or solitary. Extra-cutaneous involvement, is more common in toddlers and when multiple lesions are present. The eye is the most affected site. We highlight this clinical case by its presentation in the neonatal period and in the form of multiple lesions, which bestows an increased risk of extra-cutaneous involvement, although this has not yet been verified.

Giant Juvenile Xanthogranuloma: Case Report, Literature Review, and Algorithm for Classification

Juvenile xanthogranuloma (JXG) is a member of the non-Langerhans cell group of proliferative disorders of mononuclear phagocytes. JXG is a benign tumour of histiocytic cells. Classic JXG is divided into 2 main clinical subtypes: dome-shaped papules (<0.5 cm) and single/multiple nodules (<2.0 cm). A rare variant is referred to as giant; this term encompasses JXG lesions larger than 2.0 cm. In this article, we report a case of a congenital cutaneous giant JXG. In addition, we reviewed and analyzed all cases (n = 51) of giant JXG reported in the English literature. We propose an algorithm for classifying giant JXG based on the following factors: onset of lesions (congenital and acquired), number of lesions (solitary ± satellites and multiple), morphology of cutaneous/mucosal lesions (plaque, nodular, ulcerated-nodular, macular, and other), and extracutaneous manifestations.

Juvenile xanthogranuloma involving concurrent iris and skin: Clinical, pathological and molecular pathological evaluations

Purpose

To report a case of juvenile xanthogranuloma involving the iris and skin that clincally was diagnosed with an obvious cutaneous lesion.

Observations

A four month-old girl with hyphema and increased intraocular pressure of the left eye persisting for 2 weeks. A suspicious yellow-brown mass with nodular surface and traversed by irregular vascularization was noted on the inferior iris surface. Ultrasound biomicroscopy (UBM; 35 MHz) of the mass revealed multiple nodular irregular hyperreflective lesions in the peripheral iris. Using a biopsy of an obvious cutaneous abdominal skin lesion a diagnosis was made based on histopathological analyses. The biopsy showed dense dermal infiltrate consisting of foamy histiocytes. Additional stains revealed CD68 positivity and CD1a and S100 negativity. This mass revealed histopathologic features identical to juvenile xanthogranuloma and was concurrent with the iris lesion. Next-generation sequencing using Ion AmpliSeqTM Cancer Hotspot Panel revealed a missense mutation of FGFR3 (p.F386L).

Conclusion and importance

The diagnosis of a xanthogranuloma of the iris with hyphema can be made easier in patients with obvious cutaneous lesions as described in our case. The significance of FGFR3 mutation in association with JXG is unknown and should be further investigated.

The clinical spectrum of xanthomatous lesions of the eyelids

Yellowish papules, nodules, or plaques, namely "xanthomatous" lesions, may be seen on the eyelids in the course of various disorders. The prototype is "xanthelasma palpebrarum" (XP) that is localized only to the eyelids and may be associated with hyperlipidemia. On the other hand, different types of normolipemic disorders may also cause xanthomatous eyelid lesions. Among these, Langerhans cell histiocytosis, diffuse normolipemic xanthoma, and non-Langerhans cell histiocytoses (papular xanthoma, juvenile xanthogranuloma, xanthoma disseminatum, adult-onset xanthogranuloma, adult-onset asthma and periocular xanthogranuloma, necrobiotic xanthogranuloma, Erdheim-Chester disease, Rosai-Dorfman disease, and reticulohistiocytosis) can be listed. The eyelid findings of this heterogeneous group of disorders are challenging to differentiate from each other due to common clinical aspects that may even sometimes mimic XP. Nodularity, induration, ulceration, diffuse eyelid involvement, and extension from eyelids to the neighboring skin may represent the clinical features of xanthomatous lesions other than XP. It is necessary to obtain a thorough history and exclude XP and then perform detailed dermatological and systemic examination, biopsy for histopathologic confirmation, and appropriate specific imaging screens. As some of the conditions may be associated with other systemic disorders, especially malignancies, the differentiation of xanthomatous eyelid lesions has a critical importance, and clinical signs can be guiding.

Hemosiderotic Juvenile Xanthogranuloma

Juvenile xanthogranuloma is a non-Langerhans cell lesion mostly limited to the skin but occasionally presenting in extracutaneous locations or associated with systemic conditions. Lesions need to be distinguished mainly from dermatofibroma, xanthoma, Langerhans cell histiocytosis, or reticulohistiocytoma. Herein, we present a hemosiderotic variant of juvenile xanthogranuloma in a 12-year-old girl, which we have not found described in literature. The lesion presented at the back of the scalp as a slowly growing yellowish polypoid lesion showing occasional bleeding. The histopathological examination demonstrated a cellular infiltrate expanding the dermis, with a Grenz zone and with no remarkable changes in the overlying epidermis. The papule was made of mononucleated macrophages, many of which were xanthomatous. There were some Touton giant cells. The lesion was intermingled with a mild inflammatory infiltrate comprising lymphocytes, plasma cells, neutrophils, and some eosinophils. Many of the macrophages contained abundant cytoplasmic deposits of iron. The macrophages expressed CD68 and CD163, whereas they failed to express S100 protein, CD1a, and Langerin.

A Rare Case of Solitary Giant Congenital Juvenile Xanthogranuloma: A Case Report

Juvenile xanthogranuloma (JXG) is the most frequent form of non–Langerhans cell histiocytosis. We present a case of giant congenital JXG in a 7-week-old boy, who had a firm and incompressible lesion, measuring 3 × 4 cm in diameter, on his right flank. The clinical appearance of the lesion and the ultrasound results suggested a vascular tumor, such as a hemangioma. Histology confirmed a JXG, although there was an absence of Touton cells, which are usually pathognomonic of JXG. In light of these findings, it would be important to include JXG in the differential diagnosis of congenital tumours, particularly vascular lesions.

Solitary Ulcerated Congenital Giant Juvenile Xanthogranuloma

A 3-month-old female patient with a giant ulcerated nodule over the back since birth was diagnosed as congenital giant juvenile xanthogranuloma (JXG) based on clinical and histopathological examination. Congenital giant JXG with ulceration at birth is a rare presentation of JXG and commonly misdiagnosed. This case emphasizes the importance of being aware of the myriad presentations of JXG in order to make a correct diagnosis and avoid unnecessary investigations or treatment.

Segmental juvenile xanthogranuloma

A 5-month-old boy had erythematous nodules over the left side of his trunk with a segmental arrangement since birth. Histopathologic examination revealed sheets of foamy histiocytes infiltrating the dermis and subcutaneous fat, admixed with multinucleated giant cells and lymphocytes, making this an unusual case of juvenile xanthogranuloma appearing in a segmental distribution.

Juvenile xanthogranuloma: a case report and review of the literature

Background

Juvenile xanthogranuloma is a rare disorder which may be present at birth, or appears in infancy. It can also occur in adults of all ages; appears with lesions that may be solitary or multiple nodules several millimeters in diameter. The predilection sites are head and neck, but it may occur on the extremities and trunk also. There can also be involved internal organs such as lung, kidney, gastrointestinal tract, etc. The most frequent extracutaneous location is the eye.

Case presentation

We report a case of juvenile xanthogranuloma in a male child with onset in the fourth month of life. He presented with a nodule 8 millimeters in diameter, tan-orange in color, ulcerated in the centre, located on the left corner of the left eye. A biopsy without total excision was performed. After the biopsy, the nodule enlarged to 1.5 cm in diameter and became haemorrhagic. The histologic evaluation and immunohistochemistry analysis resulted in the diagnosis of juvenile xanthogranuloma. For aesthetic reasons the nodule was removed by surgical resection.

Conclusion

Juvenile xanthogranuloma is on a spectrum of histiocytic disorders, which is necessary to differentiate from maligniances in childhood by biopsy.

Optical coherence tomography characteristics of epi-iridic membrane in a child with recurrent hyphema and presumed juvenile xanthogranuloma

We report a case of spontaneous hyphema in a 6-month-old girl with no history of trauma and no visible iris mass. Subtle green-blue heterochromia was noted in the right eye. The iris crypts in the right eye appeared flattened by a thin, transparent layer on the iris surface. Anterior segment optical coherence tomography (AS-OCT) disclosed a thin homogenous membrane overlying the entire iris surface in the right eye. Fluorescein angiography revealed diffuse hyperfluorescence without neovascularization. These features were suggestive of diffuse iris juvenile xanthogranuloma. Sub-Tenon's triamcinolone acetate plus topical corticosteroids eyedrops resolved the condition within 1 month.

Clustered juvenile xanthogranuloma

Clustered or agminated juvenile xanthogranuloma (JXG) is an unusual form of JXG characterized by multiple reddish-brown or yellowish papules and nodules in a coalescent pattern. We report a case of clustered JXG involving the left lower back of a 5-month-old boy.

Mitotically active xanthogranuloma: a case report with review of the literature

Juvenile xanthogranuloma is a benign histiocytic lesion that displays different histologic patterns. The classic form consists of a proliferation of foamy histiocytes admixed with numerous multinucleated Touton-type giant cells, lymphocytes, and eosinophils. Mitotic figures are rare or even absent. Apart from this classic form, a nonlipidized form showing a diffuse infiltrate of nonfoamy histiocytes with or without rare Touton-type giant cells is described. The mitotic activity is somewhat higher than in the classic form. We describe here an unusual case, occurring in a 71-year-old man, characterized by a very high mitotic index (22 mitotic figures per 10 high-power fields).

Nonlipidized juvenile xanthogranuloma: an unusual variant with a potential diagnostic pitfall

Juvenile xanthogranuloma (JXG) is a histiocytic inflammatory disorder that can present different histologic patterns. Classic JXG consists of sheets of foamy histiocytes and numerous multinucleated Touton giant cells. Nonlipidized JXG (NJXG) is one of the unusual variants of JXG, consisting of a diffuse monomorphic infiltrate of mononuclear histiocytes, suggesting an aggressive or malignant tumor due the high mitotic index. However, NJXG behaves clinically as classic JXG. We present an unusual case of a 6-year-old boy who presented an exophytic ulcerated nodule on the lower lip diagnosed as NJXG. The boy is currently well without recurrence three years after surgical excision.

Juvenile xanthogranuloma: case report and review of the literature

The present case report describes a juvenile xanthogranuloma in a five-month-old girl. A circumscribed papule was located below the right nasal ala and above the right vermilion border. The lesion was histologically diagnosed as a juvenile xanthogranuloma after surgical resection of the mass. Juvenile xanthogranuloma is an uncommon diagnosis, with the head, neck and trunk being the most common sites.

Juvenile xanthogranuloma of the ear: A case report

Juvenile xanthogranuloma is a relatively uncommon, benign histiocytic proliferative disorder. A case of juvenile xanthogranuloma in a 13-month-old girl with an unusual clinical form is described. She presented with a yellow-red projecting nodule over the helical rim of her right ear. The lesion was histologically diagnosed as juvenile xanthogranuloma after excisional biopsy. Although primarily a dermatological curiosity, plastic surgeons should be familiar with this entity, and should consider it in the differential diagnosis of benign soft tissue tumours of the ear.

Juvenile xanthogranuloma in an adult lumbar spine: a case report

STUDY DESIGN

Case report.

OBJECTIVE

To report a very rare case of juvenile xanthogranuloma (JXG) of the spine in an adult.

SUMMARY OF BACKGROUND DATA

JXG is very rare in the spine, with only five prior reports in infants and children. To the best of our knowledge, this tumor has never been reported in an adult spine.

METHODS

The patient is a 47-year-old woman who presented with bowel and bladder incontinence. Magnetic resonance imaging showed a very large lesion arising from the L2 vertebral body, with massive extension into the retroperitoneum with extensive intradural involvement. She had decreased rectal tone, had 4/5 strength in the right hip flexor, and had diminished sensation in her anterior right thigh and perineal region. She was otherwise neurologically intact. After preoperative embolization, a decompressive laminectomy was performed and the tumor was resected through a posterolateral transpedicular approach, followed by stabilization. Because of extensive involvement of retroperitoneum, complete resection was not possible.

RESULTS

After pathologic evaluation of the specimen, a diagnosis of JXG was made. Patient underwent postoperative radiation therapy, and her neurologic examination improved significantly over the next several months.

CONCLUSIONS

To the best of our knowledge, this is the first reported case of JXG in an adult spine. Although complete resection of the tumor was not possible, decompression of the dural sac followed by postoperative radiation led to an excellent clinical outcome.

Solitary juvenile xanthogranuloma of the temporal muscle and bone penetrating the dura mater in a 2-month-old boy

Juvenile xanthogranuloma (JXG) is a rare histiocytic disorder primarily observed during the first 2 years of life. Most patients present with a solitary cutaneous lesion; however, others present with extracutaneous manifestations or even with systemic involvement. The authors describe a 2-month-old boy in whom was diagnosed a unifocal extracutaneous JXG involving the temporal bone. Unlike 3 other cases of solitary JXGs of the temporal bone in the literature, the present case involved destruction of the dura mater and leptomeningeal enhancement surrounding the entire temporal lobe. The lesion did not regress after an initial biopsy procedure and had to be removed more radically because of progressive mass effect on the brain. The child recently underwent a reconstructive skull procedure and is doing well almost 2 years postoperatively without evidence of disease. This case demonstrates that even in instances of extensive disease a favorable outcome is possible without chemotherapy.

Gingival juvenile xanthogranuloma in an adult patient: case report with immunohistochemical analysis and literature review

Juvenile xanthogranuloma (JXG) is a non-Langerhans cell histiocytosis (nonLCH). It is a benign and self-healing disorder that generally affects infants and children. Oral lesions in adult patients are rare, although the microscopic findings are similar to those observed in other locations. A 56-year-old white man presented with a chief complaint of a gingival mass that had appeared 6 months before and had grown slowly. An intraoral examination revealed the presence of a solitary, softened gingival mass affecting the mandibular lingual gingiva at the right central incisor area. A biopsy of the lesion showed multiple large macrophages and numerous giant cells of Touton type. The immunohistochemistry positivity for CD68, fascin, factor XIIIa, alpha-antitrypsin and negativity for S-100, beta-actin, CD1a, and desmin confirmed the diagnosis of JXG. The occurrence of adult oral JXG is extremely rare. It is a nonLCH that may present variable clinical and microscopic aspects, which leads to a diversity of clinical misdiagnoses. A precise diagnosis of these lesions requires an accurate evaluation of clinical, microscopic, and immunohistochemical features.

Managing isolated subglottic juvenile xanthogranuloma without tracheostomy: case report and review of literature

Juvenile Xanthogranuloma (JXG) is a dendritic cell related histiocytic disorder which usually presents in the first year of life as a solitary cutaneous granuloma. Isolated presentation in the upper airway is very rare but can result in severe respiratory distress, especially in young children. We present the case of a 5-month-old male with an isolated subglottic JXG lesion. Endoscopic excision provided symptomatic relief and avoided the need for tracheostomy. The lesion has completely resolved 17 months later. Surgical excision without tracheostomy was the treatment of choice in two of the four additional cases of upper airway JXG presented in the literature. JXG has an excellent prognosis with spontaneous regression over time. Histology alone is frequently inadequate to differentiate JXG from the more common Langerhans Cell Histiocytosis (LCH), which carries a much less favorable prognosis. The evolving field of immunohistochemistry provides an essential tool to establish the correct diagnosis. The typical phenotype of JXG is Factor XIIIa+/Fascin+/CD68+/CD163+/CD14+/CD1a-/S100-.

Severe astigmatic amblyopia secondary to subcutaneous juvenile xanthogranuloma of the eyelid

A number of eyelid lesions in early childhood, most commonly dacryoceles and hemangiomas, have been documented to cause astigmatic changes of the cornea. Juvenile xanthogranuloma (JXG) is typically reported to include both cutaneous skin and anterior ocular segment lesions. We report a case of a 10-month-old infant in which a subcutaneous JXG lesion of the lower eyelid resulted in visually significant astigmatic amblyopia.

Lumps and bumps in neonates and infants

There are many developmental abnormalities that may appear in the neonate and in infants when critical steps in embryogenesis fail. These steps are often not fatal but can lead to significant morbidity for those patients affected. A logical approach is needed in addressing both the diagnostic and therapeutic issues that arise when caring for these patients, as various lesions will warrant an observational approach, and others may require imaging studies or definitive surgical intervention. Additionally, there are other "lumps and bumps" that are seen in the neonatal and infantile age groups that include malignancies and cutaneous neoplasms with associated systemic sequelae.