Sclerema Neonatorum**From the Medical Research Council, Unit for Research on the Experimental Pathology of the Skin, The Medical School, University of Birmingham, Birmingham 15, England

Sclerema Neonatorum in a Term Infant: A Case Report and Literature Review

Sclerema neonatorum (SN) is a rare form of panniculitides with an obscure incidence, aetiology, and pathogenesis. This condition is peculiar to preterm neonates, especially those with comorbidities such as sepsis, congenital anomalies, congenital heart disease, and gastrointestinal and respiratory diseases. Usually, it presents within the first seven days of life, but may develop a few weeks later. Typically, SN manifests with diffuse hardening of the skin and subcutaneous tissues that subsequently bind to the underlying muscle and bone, often beginning in the buttocks, thighs, or trunk, and progressing to other body parts, but sparing the soles, palms, and genitalia. Diagnosis is based on clinical characteristics. It has been associated with a high mortality, despite aggressive use of various treatment modalities such as antibiotics, steroids, fresh blood transfusion, exchange blood transfusion, and intravenous immunoglobins. This is a report of a macrosomic term neonate who presented with typical clinical and histopathological features of SN.

Subcutaneous fat necrosis of the newborn and associated hypercalcemia: A systematic review of the literature

Subcutaneous fat necrosis of the newborn is an uncommon disorder, and although usually benign, associated hypercalcemia can lead to complications such as failure to thrive and renal failure. Many sources suggest screening for hypercalcemia for 6 months following resolution of skin lesions, but little data are available to support this recommendation. This study examines existing published literature to better guide practitioners regarding screening evaluations of asymptomatic patients with subcutaneous fat necrosis. A systematic review of the literature was conducted using a PubMed English literature search. Data from case reports and case series were collected regarding the presence of hypercalcemia and associated complications, birth history, and age of onset/resolution of skin lesions and laboratory abnormalities. Approximately half (51%) of infants reported had hypercalcemia. Most (77%) developed detectable hypercalcemia within 30 days of skin lesion onset, and 95% developed detectable hypercalcemia within 60 days of skin lesion onset. Hypercalcemia was detected in only 4% of patients > 70 days following onset of skin lesions. Seventy-six percent had resolution of hypercalcemia within 4 weeks of detection. Hypercalcemia was more prevalent in full-term vs pre-term infants (P-value = 0.054), and higher birthweight was significantly associated with an increased risk of developing hypercalcemia (P-value = 0.022). Although gestational age trended toward significance, the only statistically significant clinical feature predicting the development of hypercalcemia was higher birthweight. Current recommendations for laboratory monitoring are not evidence-based, and this study provides interim data to guide practitioners until prospective, randomized controlled trials are conducted.

Factors associated with sclerema in infants with diarrhoeal disease: a matched case-control study

AIM

To identify clinical and biochemical factors associated with sclerema in infants with diarrhoeal illness, and their outcome.

METHODS

In this case-control study, we enrolled 30 infants with clinical sepsis with sclerema (cases) and another 60, age- and sex-matched infants with clinical sepsis but without sclerema (controls) from among those admitted to the special care unit (SCU) and longer stay unit (LSU) of the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) for their diarrhoeal illness from May 2005 through April 2006. Sclerema as the dependant variable while hypoxia, hypothermia, C-reactive protein (CRP) level, serum total protein and prealbumin level were the major independent variables compared in the analysis. Differences in proportions were compared by the chi-square test and differences of mean were compared by Student's t-test or Mann-Whitney test, as appropriate.

RESULTS

The case-fatality was significantly higher among the cases than the controls (30% vs. 2%, CI 2.9-565.5). After adjusting for confounders, infants with sclerema were more likely to be hypothermic (OR 11.6, 95% CI 1.1-126.5), and have lower serum total protein (OR 1.12, 95% CI 1.04-1.21) and prealbumin (OR 1.5, 95% CI 1.1-2.3).

CONCLUSION

Diarrhoeal infants having clinical sepsis presenting with hypothermia, lower serum protein and prealbumin are prone to be associated with sclerema.

Sclerema neonatorum: a review of nomenclature, clinical presentation, histological features, differential diagnoses and management

OBJECTIVE

To review published literature on sclerema neonatorum (SN) in order to clarify its clinical presentation, histological features and management compared with two other diseases: subcutaneous fat necrosis of the newborn (SCFN) and scleredema.

STUDY DESIGN

PubMed database was searched using the key words Sclerema neonatorum. A total of 55 articles from peer-reviewed journals were reviewed and summarized.

RESULT

SN, SCFN and scleredema are diseases of the subcutaneous adipose tissue. SN is characterized by hardening of the skin that gets bound down to the underlying muscle and bone, hindering respiration and feeding and is associated with congenital anomalies, cyanosis, respiratory illnesses and sepsis. Histology of the skin biopsy shows thickening of the trabeculae supporting the subcutaneous adipose tissue and a sparse inflammatory infiltrate of lymphocytes, histiocytes and multinucleate giant cells. SCFN has circumscribed hardening of skin on bony prominences with necrosis of adipocytes in subcutaneous tissue and a dense granulomatous infiltrate on histology. Scleredema is characterized by hardening of the skin along with edema; histology shows inflammatory infiltrate and edema in skin and subcutaneous tissues. SN has a high case fatality rate whereas SCFN and scleredema are self-limiting and lesions resolve within a few weeks to months. Exchange transfusion may improve survival in SN.

CONCLUSION

The histological features of skin biopsy should be used to establish diagnosis of SN, SCFN and scleredema as disease-specific treatment is imperative in SN due to high fatality.

Complications of subcutaneous fat necrosis of the newborn: a case report and review of the literature

Subcutaneous fat necrosis of the newborn is an uncommon, self-limited panniculitis of neonates. Rare complications such as hypercalcemia, thrombocytopenia, hypertriglyceridemia, and hypoglycemia have been reported. We describe the first case where all of the above complications were encountered in the same infant. Physicians caring for infants with subcutaneous fat necrosis of the newborn should be aware of the above associations in order to provide prompt and appropriate treatment to prevent associated, undesirable sequelae.

Subcutaneous fat necrosis, hypercalcemia, and prostaglandin E

We present two patients with subcutaneous fat necroses (SCFN) in whom endocrinologic studies revealed an association with elevated prostaglandin E (PGE) levels. A boy born after prolonged labor complicated by meconium aspiration developed erythematous, indurated plaques over the back, arms, buttocks, and cheeks at 4 days of age. A biopsy specimen of involved skin showed panniculitis with foci of necrotic adipocytes containing radially arranged, needle-shaped clefts and a granulomatous infiltrate in the septae. Laboratory studies revealed hypercalcemia of 13.6 mg/dl (normal 8.8-10.1 mg/dl), elevated 1.25-1.25(OH)2D3, and increased urinary excretion of PGE2. The child was hospitalized and treated with systemic steroids and diuretics, with resolution of SCFN and hypercalcemia. The second patient was a girl born with cyanotic heart disease. A diagnosis of Ebstein anomaly was made, and intravenous PGE1 was started to keep patent the ductus arteriosus. Four days later erythematous, indurated plaques were noted on the knee, back, and anterior chest. A skin biopsy specimen revealed SCFN. There was no associated laboratory abnormality. On discontinuing PGE1, no new lesions formed and the existing panniculitis resolved. These two cases demonstrate the association between SCFN and elevated PGE levels (endogenous in patient 1, exogenous in patient 2). No previous reports of SCFN after the administration of PGE1 have appeared in the literature.

Subcutaneous fat necrosis in a neonate, in association with aberrant plasma lipid and lipoprotein values

A newborn infant with subcutaneous fat necrosis after perinatal hypoxia was found to have several abnormalities of plasma lipids. Further studies are needed to determine whether such abnormalities contribute to the pathophysiology of the skin lesions.

Lipid-rich cell thyroid adenoma: histopathology with comparative lipid analysis

A second case of the unique lipid-rich cell thyroid adenoma is described complemented by detailed lipid analysis. New observations were made. The cytoplasm of the tumour cells contained scattered, aggregated sudanophil crystals; under polarized light the frozen, unstained sections exhibited numerous birefringent lipid crystals; electron microscopy provided further evidence that the clear cell appearance was due to intracellular lipid droplets with scanty glycogen particles. Comparative lipid analysis by thin layer chromatography and high-pressure liquid chromatography (HPLC) revealed quantitative and qualitative differences in lipid composition of tumour cells when compared with goitre cells from normal thyroid gland and subcutane fat. Qualitative differences in triglyceride composition (by HPLC) between tumour cells and subcutaneous fat indicated that the fat accumulation in the follicle cells was not a result of simple storage, but an expression of altered intracellular lipid metabolism.

Subcutaneous fat necrosis of the newborn: light, ultrastructural and histochemical microscopic studies

Multiple subcutaneous plaques and nodules appeared on the back and the dorsal proximal area of the extremities of a 9-day-old male infant after a complicated prenatal period necessitating cesarean section. The clinical and histological features were diagnostic of subcutaneous fat necrosis of the newborn. Light microscopy revealed adipocyte necrosis, a lymphohistiocytic infiltrate, and needle-shaped clefts within adipocytes and macrophages. Ultrastructurally, there were aggregations of electron-lucent spaces in the form of spindles and needles arranged in parallel within the altered adipocytes; macrophages surrounded these cells or their fragments and invaded the fat lobules. Enzyme histochemical staining, not previously reported in the literature, showed that acid phosphatase, leucine aminopeptidase, and indoxyl and non-specific esterases were present in the areas of fat necrosis.

Sclerema neonatorum and subcutaneous fat necrosis of the newborn

Sclerema neonatorum and subcutaneous fat necrosis are rare disorders affecting the panniculus of the newborn. This review attempts to put into perspective their similarities and differences in light of historical, biochemical, pathologic, and etiologic considerations. Recent therapeutic modalities and the prognosis are discussed.

Subcutaneous fat necrosis in an infant, occurring after hypothermic cardiac surgery. Case report and analysis of etiologic factors

A female infant developed extensive subcutaneous fat necrosis 3 weeks following induced hypothermia used as an adjuvant in cardiac surgery. All lesions resolved without sequelae within 4 months. In this article we discuss the various causes of panniculitis in infants and the relevance of each cause to our patient. We believe that an underlying defect in composition and metabolism of fat, coupled with a variety of exogenous and endogenous stresses, can precipitate subcutaneous fat necrosis in infants. These stresses include physical trauma (e.g., hypothermia), poor nutrition, infection, and metabolic abnormalities.

Restrictive dermopathy: a newly recognized autosomal recessive skin dysplasia

A brother and sister from consecutive pregnancies had rigid and tightly adherent skin in association with generalized contractures, unusual facies, pulmonary hypoplasia, an abnormal placenta, and a short umbilical cord. Both died shortly after birth. Pathologic examination of the skin by light and electron microscopy showed structural abnormalities of the epidermis, dermis, and subcutaneous fat. An abnormal pattern of keratin proteins was determined biochemically using extracted epidermal proteins. Autopsy showed a normal spinal cord and muscle histology. It is postulated that the defective skin severely restricted movement and secondarily led to the other abnormalities. Familial occurrence is most consistent with autosomal recessive transmission. These patients and the primary skin defect are discussed within the framework of the Fetal Akinesia or Hypokinesia Deformation Sequence.

Subcutaneous fat necrosis of the newborn

A case of subcutaneous fat necrosis of the newborn is described. Severe perinatal asphyxia preceded the appearance of the skin lesions. Premature rupture of membranes and the presence of foul-smelling meconium raised the possibility of infection by anaerobes as an additional etiologic factor. The main hypotheses concerning the cause and pathogenesis of this condition are reviewed. The alarming clinical picture that stands in sharp contrast to the benign prognosis is stressed.

Sclerema neonatorum. Light and electron microscopic studies

Specimens from four cases of sclerema neonatorum were studied by light and electron microscopy. The connective tissue bands of the cutis and subcutis were thickened and alternated with loosely distributed bands in broad, distended areas of basal substance. Extensive areas areas filled with cross-banded structures were observed in the dermis. In the interlobular septa of the subcutaneous and perirenal fat splitting of fibers into microfibrils was visible. Changes in the capillaries and small blood vessels were also noted. Neither fat cells filled with rosettes of needle-like crystals, nor any inflammatory infiltrates of foreign body type giant cells were found in subcutaneous tissue.

Studies on subcutaneous fat necrosis of the newborn

Biopsy specimens from the skin and subcutaneous fat tissue of four cases with neonatal subcutaneous fat necrosis were made and investigated by light and electron microscopy at 2, 4, and 6 weeks, and 5 months (Case 2) from the onset of the disease. Three stages of ultrastructural change of fat cells were observed. The evolution of crystal formation in the fat cells was seen and phagocytosis of crystals and fat droplets by macrophages and foreign-body giant cells was also noted. In the light microscope accumulation of calcium concretions in the spaces between and inside the fat cells was found. In the electron microscope we detected foci of highly electron-dense granules, which were similar in distribution and structure to calcium salts stained with the von Kossa method. Changes in small and medium size blood vessels were observed.

Subcutaneous fat necrosis of the newborn

Subcutaneous fat necrosis of the newborn (SFNN) developed in a 1-week-old black boy. His mother had received numerous medications for eclampsia. Birth was by Caesarean section and complicated by meconium aspiration. There were numerous nodules over the back, buttocks and extremities that yielded a caseous-like material. Microscopically, these nodules showed crystallization and necrosis of the fat. Hypoglycemia, pneumonia, oliguria, thrombocytopenia, seizures and urinary infection were associated with the cutaneous problem and led to a fatal outcome 2 weeks after birth.

Subcutaneous fat necrosis of the newborn: Light and electron microscopic studies

Specimens from two cases of subcutaneous fat necrosis of the newborn were studied by light and electron microscopy. Crystallization of the fat cell started with clearing of the central fat droplet, followed by the appearance of cylindrical crystals. The fat crystals were phagocytosed by cytoplasmic projections of macrophages as well as by foreign body giant cells. Calcium deposits were demonstrated within the central fat droplet of the degenerated fat cell of Case 2.