Effect of Tranexamic Acid on Intra- and Postoperative Bleeding in Eyelid Surgery: A Prospective, Randomized, Multicenter, Double-Masked, Control Trial

PURPOSE

Pilot studies suggest that waiting 15 minutes after a subcutaneous tranexamic acid injection is associated with decreased intraoperative bleeding and postoperative ecchymosis in eyelid surgery. The outcomes of commencing eyelid surgery immediately after injection without a waiting period remain unexplored.

METHODS

This prospective, randomized, multicenter, double-masked, controlled study examined bilateral symmetric upper and/or lower lid blepharoplasty or ptosis repair. Patients received tranexamic acid in 1 eyelid and control in the contralateral eyelid. The surgeon recorded the side with more intraoperative bleeding. Two masked graders evaluated periocular ecchymosis at postoperative day 0 and postoperative week 1 (POW 1) with a 5-point scale. At POW 1, patients reported subjective grading of bruising as increased on 1 side or similar on both sides. Results were analyzed with Wilcoxon signed-rank and sign tests.

RESULTS

Of 130 patients, there was less eyelid ecchymosis on the tranexamic side at postoperative day 0 ( p = 0.001) and POW 1 ( p < 0.001). By surgery type, the 69 levator advancement surgeries had significantly less ecchymosis at postoperative day 0 ( p < 0.001) and POW 1 ( p = 0.001), while upper eyelid blepharoplasty, combined upper and lower lid blepharoplasty, and conjunctivomullerectomy trended toward significance. Of 68 patients reporting a POW 1 grading, 69% reported less bruising on the tranexamic side ( p < 0.001). Intraoperative bleeding was not significantly different between sides ( p = 0.930).

CONCLUSIONS

Without a postinjection waiting period, subcutaneous tranexamic acid for eyelid surgery significantly decreased postoperative ecchymosis on postoperative day 0 and POW 1 but did not affect intraoperative bleeding. Subcutaneous tranexamic acid was not associated with any complications.

Raccoon Eyes Presentation in a Child Diagnosed With Acute Lymphoblastic Leukemia: A Case Report

Raccoon's eyes (periorbital ecchymosis) may present as the first sign in patients with skull base/base/facial fractures and tumors. In childhood, orbital metastases of neuroblastoma should be considered in the absence of trauma history. Herein, we report a 3-year-old girl diagnosed with acute lymphoblastic leukemia who presented with periorbital ecchymosis. To the best of our knowledge, this is the first pediatric patient with acute lymphoblastic leukemia in the literature who presented with raccoon eyes.

A Multi-stage Segmentation Method for Tongue Ecchymosis. Annu Int Conf IEEE Eng Med Biol Soc 2023;2023:1-4. [PMID: 38083193 DOI: 10.1109/embc40787.2023.10340439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Tongue diagnosis is an important component of traditional Chinese medicine (TCM), in which tongue ecchymosis is the main diagnostic basis for the blood stasis syndrome of TCM. Most of the existing methods are unsupervised and cannot accurately segment tongue ecchymosis. In this paper, we propose a multi-stage segmentation method for tongue ecchymosis. We first employ an object detection model for rough localization of tongue ecchymosis, and then use the unsupervised clustering and the watershed transform for rough segmentation and fine segmentation of tongue ecchymosis respectively. To the best of our knowledge, we are the first to combine machine learning and deep learning to segment tongue ecchymosis. Experimental results show that the tongue ecchymoses obtained by our method are more similar to the real tongue ecchymoses compared with the existing methods, and the Intersection-over-Union (IoU) is improved by 0.12 compared with the latest method.Clinical Relevance-Tongue ecchymosis obtained by this paper is the main diagnostic basis for the blood stasis syndrome of TCM.

Spontaneous ecchymoses

The patient's lifestyle was undoubtedly to blame for the appearance of her skin. The loss of her beloved pet may have been a tipping point.

A refugee child with multiple patterned ecchymoses: a diagnostic dilemma between nonaccidental injury and primary hemostatic defect

A 4-year-old girl from Syria presented to the hospital with multiple bruises on her body. Bruises were observed in protected areas in a shape of fingerprints and objects, while no other bruises occurred during hospitalization. The parents also reported a history of bleeding diathesis from infancy. Both the initial laboratory evaluation and the secondary tests done for possible thrombocytopenia and coagulation factors deficiencies were normal. Thus, the nonaccidental injury protocol of the Hospital was activated, and the possibility of abuse was not quite evident. Investigation for platelet disorders followed. Platelet aggregation test and flow cytometry were indicative of Glanzmann's thrombasthenia. It is of great importance in these cases, that the doctor eliminates any possibility of physical abuse and examines the patient for common and rare primary hemostatic defects, although both can co-exist.

Dermatological Toxicities of Bruton's Tyrosine Kinase Inhibitors

The development of Bruton's tyrosine kinase (BTK) inhibitors represents a major breakthrough in the treatment of chronic lymphocytic leukemia and other B cell malignancies. The first-generation inhibitor ibrutinib works by covalent irreversible binding to BTK, a non-receptor tyrosine kinase of the TEC (transient erythroblastopenia of childhood) family that plays a critical role in the B-cell receptor signaling pathway. It also induces an 'off-target' inhibition of a range of other kinases including (but not limited to) epidermal growth factor receptor (EGFR), SRC, and other kinases of the TEC family (interleukin-2-inducible T-cell kinase [ITK], Tec, BMX). Dermatological toxicities are among the most common toxicities of ibrutinib, but remain of mild to moderate intensity in most cases and are readily manageable. Their incidence is highest during the first year of treatment and declines over time. In addition, it has been postulated that ibrutinib-related dermatologic adverse events are mediated by the direct binding to both BTK and other 'off-target' kinases. Bruising, ecchymoses, and petechiae represent the most characteristic dermatologic adverse events. Nail and hair changes are also common, as skin infections (opportunistic infections including herpes simplex and herpes zoster virus reactivations, and Staphylococcus aureus superinfection), folliculitis, and other types of rashes. Panniculitis, aphthous-like ulcerations with stomatitis, neutrophilic dermatosis, peripheral edema, and skin cracking can also occur. Next-generation BTK inhibitors, acalabrutinib and zanubrutinib, have been designed to optimize BTK inhibition and minimize off-target inhibition of alternative kinases (Tec, ITK, EGFR, SRC-family kinases). These drugs have been recently FDA-approved for relapsed or refractory mantle cell lymphoma. Although the overall incidence of their toxicities is expected to be more limited, acalubrutinib and zanubrutinib are associated with a range of dermatologic toxic effects that appear to be similar to those previously described with ibrutinib, including bruising and ecchymoses, panniculitis, human herpesvirus infections, cellulitis, and skin rash. In particular, both drugs induce skin bleeding events in more than 30% of patients treated. However, the available dermatological data are still rather limited and will have to be consolidated prospectively. This review article analyses the wide spectrum of dermatological toxicities that can be encountered with first- and second-generation BTK inhibitors. Finally, recommendations for appropriate treatment as well as a synthesis algorithm for management are also proposed.

Acquired hemophilia A in a woman with systemic lupus erythematosus: A case report and review of literature

RATIONALE

Acquired hemophilia A (AHA) is a rare autoimmune disease caused by autoantibodies directed against the activity of factor VIII (FVIII) and presents with prolonged bleeding. 5.7% of systemic lupus erythematosus (SLE) patients are affected by AHA.

PATIENT CONCERNS

A 51-year-old female patient with SLE presenting with the fatigue and spontaneous clinical bleeding symptoms such as hematuria and ecchymoses for 1 week.

DIAGNOSIS

Laboratory examinations revealed prolongation of the activated partial thromboplastin time (APTT) (65.7 s), decreased FVIII activity (1.4%), and a titer of FVIII inhibitors of 8.5 Bethesda units/mL.

INTERVENTIONS

Transfusion of recombinant human FVIII (ADVATE) in combination with intravenous methylprednisolone, cyclophosphamide, plasmapheresis, and fresh frozen plasma successfully stopped the bleeding and reduced the level of FVIII inhibitor.

OUTCOMES

The size of the hematoma slowly decreased. The skin ecchymosis was gradually absorbed, the hemoglobin count increased, and the coagulation index gradually improved. There was no new bleeding or bleeding site. The patient was discharged and transferred to a local hospital for hospice care.

LESSONS

AHA in a patient with SLE is rare. Once it occurs, it can be life-threatening. Clinicians should remain aware that because some cases of AHA may have features of SLE, appropriate distinction and diagnosis of these different but associated diseases is necessary.

Bilateral Periorbital Ecchymosis Following Ablative Laser Removal of Xanthelasma Palpebrarum

Periocular ecchymosis is a rare finding with various, sometimes life-threatening pathologies. We report the case of a 48-year-old woman who presented with bilateral periocular ecchymosis after laser removal of xanthelasma palpebrarum. Her medical history was unremarkable. Amyloidosis could be excluded by histopathology. We suggest that periocular ecchymosis is a rare adverse event after minor (laser) surgery of the eyelids and discuss the possible pathogenesis and differential diagnoses.

Periorbital ecchymoses and breathlessness

A 54-year-old man presented at our facility with a 3-month history of exertional breathlessness and purple blotches around his eyes. Examination revealed bilateral periorbital and perioral ecchymosis, purpuric spots along his waist, and waxy papules on his eyelids. In addition, the patient had macroglossia with nodular infiltration and irregular indentations at the lateral margin of his tongue. The patient also had a raised jugular venous pressure and prominent atrial and ventricular waves. Further examination revealed a fourth heart sound over the left ventricular apex, as well as bilateral basal rales. All other systems were normal except for mild hepatomegaly. Routine hematologic and biochemical lab work was unremarkable. X-rays of the spine and skull were normal, but a chest x-ray showed mild cardiomegaly. An electrocardiogram showed a QS complex from leads V1 to V4 (a pseudo-infarction pattern). An echocardiogram showed biatrial enlargement, left ventricular hypertrophy with a left ventricular ejection fraction of 48%, a speckled pattern on the myocardium, a thickened interatrial septum, and mild pericardial effusion. A color Doppler revealed mild mitral and tricuspid regurgitation with a restrictive pattern of mitral valve flow. Serum protein electrophoresis was normal. WHAT IS YOUR DIAGNOSIS? HOW WOULD YOU TREAT THIS PATIENT?

Double-Blind Comparison of Ultrasonic and Conventional Osteotomy in Terms of Early Postoperative Edema and Ecchymosis

BACKGROUND

Edema and ecchymosis are common complications of rhinoplasty. Modifications to osteotomy may reduce edema and ecchymosis and ameliorate postoperative discomfort in patients who undergo rhinoplasty.

OBJECTIVES

The authors performed osteotomy with conventional instruments or with an ultrasonic device and compared these methods with respect to the severities of ecchymosis and edema in the early postoperative period.

METHODS

Fifty-six patients who underwent primary rhinoplasty with medial oblique, low-to-high internal osteotomy performed conventionally or with an ultrasonic device were evaluated in a prospective study. Photographs of the patients on postoperative days 3 and 7 were scored for ecchymosis and edema by 2 physicians who did not perform the operations and were blinded to the osteotomy procedure.

RESULTS

Ecchymosis scores on postoperative days 3 and 7 and edema scores on postoperative day 3 were significantly higher for the 22 patients who underwent conventional osteotomy than for the 34 patients who underwent ultrasonic osteotomy, as scored by both examiners. Edema scores on postoperative day 7 were significantly higher for conventional than for ultrasonic osteotomy as assessed by 1 examiner but were not significantly different as determined by the other examiner.

CONCLUSIONS

The results of this comparative study suggest that rhinoplasty with ultrasonic osteotomy is associated with less edema and ecchymosis in the early postoperative period than is rhinoplasty with conventional osteotomy.

LEVEL OF EVIDENCE

3 Therapeutic.

Perioperative Corticosteroids Reduce Short-Term Edema and Ecchymosis in Rhinoplasty: A Meta-Analysis

BACKGROUND

A number of randomized controlled trials (RCTs) have investigated the role of perioperative corticosteroids in rhinoplasty. Each of these trials however has an insufficient sample sizes to reach definitive conclusions and detect harms. Three recent reviews have analyzed edema and ecchymosis outcomes following rhinoplasty; each arrived at a different conclusion and recommendation.

OBJECTIVE

To estimate the effectiveness of systemic perioperative corticosteroid treatment compared to placebo for clinical outcomes in rhinoplasty using a methodologically rigorous meta-analysis.

METHODS

Electronic databases were searched without language restriction. Included trials were randomized controlled trials of systemic perioperative corticosteroid treatment vs placebo in rhinoplasty evaluating at least one of: edema, ecchymosis, bleeding, cosmetic outcome, and patient satisfaction. The Cochrane risk of bias tool was applied to included trials, and the quality of evidence for each outcome was assessed using the GRADE approach.

RESULTS

Analyses included 336 patients from eight trials. Perioperative corticosteroids reduced the worst edema (SMD: -1.03, 95%CI -1.30 to -0.76, P < .001) and ecchymosis (SMD: -0.78, 95%CI -1.09 to 0.47, P < .001) after rhinoplasty. At one day postoperative, a single dose of perioperative corticosteroid reduced edema (SMD -1.15, 95%CI -1.42 to -0.87, P < .001) and ecchymosis (SMD -0.79, 95%CI -1.05 to -0.52, P < .001). No clinical benefit in edema or ecchymosis was found seven days postoperatively, nor did intraoperative bleeding increase.

CONCLUSIONS

There is high quality evidence to support perioperative systemic corticosteroid treatment in rhinoplasty to reduce short-term edema and ecchymosis without increased intraoperative bleeding. These findings are not present at seven days. For future trials, we suggest evaluation of patient satisfaction, and correlation with long-term cosmetic outcome. LEVEL OF EVIDENCE 2: Therapeutic.

A Review of Clinical Signs Related to Ecchymosis

Ecchymosis is a large area of discoloration caused by extravasation of blood into the subcutaneous tissue. It is an objective physical finding that may provide valuable clues as to its possible etiology. Ecchymosis is associated with eponyms based on the physician who first described the physical findings, which can be divided into 4 anatomical categories: base of the skull, abdominal wall and retroperitoneum, groin and scrotum, and lower extremity. Classic external signs and eponyms associated with ecchymosis are reviewed. Knowledge of these signs on physical examination may prove to be a useful clue directing the examiner to consider potentially serious causes of disease.

Three-dimensional reconstruction and surface extraction of lower limbs as visualization methodologies of ecchymosis

This paper presents a computational system for three-dimensional reconstruction and surface extraction of the human lower limb as a new methodology of visualizing images of multifaceted ecchymosis on the lower limbs. Through standardization of image acquisition by a mechanical system, an algorithm was developed for three-dimensional and surface reconstruction based on the extraction of depth from silhouettes. In order to validate this work, a three-dimensional model of the human lower limb was used inside a virtual environment. At this environment the mechanical procedure of image acquisition was simulated, resulting in 100 images which was later submitted to all algorithms developed. It was observed that the systems for three-dimensional reconstruction and surface extraction of the object were able to generate a new visualization method of the lesion. The results allow us to conclude that the developed systems provided adequate three-dimensional and two-dimensional visualization of the surface of the simulated model. Despite the lack of experiments with real ecchymoses, the systems developed in this work show great potential to be included in the standard methods for the visualization of ecchymoses.

Episiotomy healing assessment: Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability

OBJECTIVE

to analyse the Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability when evaluating perineal healing after a normal delivery with a right mediolateral episiotomy.

METHOD

observational study based on data from a clinical trial conducted with 54 randomly selected women, who had their perineal healing assessed at four time points, from 6 hours to 10 days after delivery, by nurses trained in the use of this scale. The kappa coefficient was used in the reliability analysis of the REEDA scale.

RESULTS

the results indicate good agreement in the evaluation of the discharge item (0.75< Kappa ≥0.88), marginal and good agreement in the first three assessments of oedema (0.16< Kappa ≥0.46), marginal agreement in the evaluation of ecchymosis (0.25< Kappa ≥0.42) and good agreement regarding redness (0.46< Kappa ≥0.66). For the item coaptation, the agreement decreased from excellent in the first assessment to good in the last assessment. In the fourth evaluation, the assessment of all items displayed excellent or good agreement among the evaluators.

CONCLUSION

the difference in the scores among the evaluators when applying the scale indicates that this tool must be improved to allow an accurate assessment of the episiotomy healing process.

Episiotomy healing assessment: Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability

OBJECTIVE

to analyse the Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability when evaluating perineal healing after a normal delivery with a right mediolateral episiotomy.

METHOD

observational study based on data from a clinical trial conducted with 54 randomly selected women, who had their perineal healing assessed at four time points, from 6 hours to 10 days after delivery, by nurses trained in the use of this scale. The kappa coefficient was used in the reliability analysis of the REEDA scale.

RESULTS

the results indicate good agreement in the evaluation of the discharge item (0.75< Kappa ≥0.88), marginal and good agreement in the first three assessments of oedema (0.16< Kappa ≥0.46), marginal agreement in the evaluation of ecchymosis (0.25< Kappa ≥0.42) and good agreement regarding redness (0.46< Kappa ≥0.66). For the item coaptation, the agreement decreased from excellent in the first assessment to good in the last assessment. In the fourth evaluation, the assessment of all items displayed excellent or good agreement among the evaluators.

CONCLUSION

the difference in the scores among the evaluators when applying the scale indicates that this tool must be improved to allow an accurate assessment of the episiotomy healing process.

Recurrent bilateral periorbital and circumoral bruising due to vomiting

Periorbital ecchymosis is due to extravasations of blood into the periorbital skin and the subcutaneous tissues around the eyes. 'raccoon eyes' or 'panda sign' is a distinctive type of periorbital ecchymosis where the bruising is characterised by tarsal sparing. This sparing is due to an anatomical structure called the orbital septum, which limits the spread of the discolouration beyond the tarsal plate. Hence 'raccoon eyes' description should be limited to orbital ecchymosis due to basal skull fractures only. While the bilateral bruising due to direct trauma to the eyes, or non-traumatic medical conditions, can spread beyond the tarsal plate as in our case. The differential diagnosis varies from trivial benign conditions to serious life-threatening illnesses. We describe a case of recurrent bilateral periorbital ecchymosis and facial bruising due to vomiting.

[Incorrect identification in forensic medicine (wrong conclusion): a case report]

Correct identification of lesions in examined patients is as important in forensic medicine application as it is in the medical profession. However, general practitioners and clinicians often fail to give proper attention to the definition and recording of the lesions and clinical findings in patients. Additionally, the identification of the lesion is sometimes deficient or incorrect. This has hindered, particularly in traumatic events that are of a forensic nature, reaching accurate conclusions during the interpretative and legal phases. In this study, we describe the case of a nine-year-old boy admitted to the hospital following a traffic accident. During his evaluation, an ecchymosis "resembling a rail" on his chest was noted. Consequently, legal/judicial authorities suspected the child may have been exposed to violence or child abuse and he was referred to our department. Practitioners may contribute to inaccurate decisions/conclusions if they fail to give the necessary detailed attention during the forensic interpretation (detailed examination and recording of lesions) and judicial process or if they have insufficient knowledge on this subject. This case is submitted as an interesting example since it included the possibility of inaccurate conclusion and judgment.

Injuries to the cervix in sexual assault victims

Little research has addressed the types and meaning of genital injury in sexual assault victims. An even smaller amount of research exists documenting injury to the cervix in sexual assault victims. The purpose of this study was to examine the frequency of cervical injuries in women following sexual assault, the types of injuries seen, the mechanisms that are related to the injuries, and the types of injuries related to each mechanism. A retrospective chart review was conducted. A total of 538 charts were examined, with a final sample size of 114. Within this sample, 87.8% (n= 100) presented with no injury to the cervix, and 12.3% (n= 14) had documented injury. All statistical analyses were nonsignificant; however, clinical implications are noted. Recommendations for future research are made.

Minocycline-induced pigmentation mimicking persistent ecchymosis

We report an unusual case of minocycline-induced pigmentation mimicking persistent ecchymosis in a patient with persistent (20 months' duration) bluish black discoloration of the medial and lateral aspects of the left ankle following an avulsion fracture. We review the common presentations of minocycline-induced pigmentation as well as some of the more unusual presentations.

[Traumatic lumbosacral fracture dislocation: a case report and review of the literature]

Lumbosacral dislocation is uncommon. We report a case of traumatic lumbosacral dislocation which occurred in a 33-year-old pedestrian traffic accident victim. The posterior impact produced lumbar injury with diffuse pain exacerbated at the lumbosacral junction. Ecchymotic diffusion involving the entire lumbar region fluctuated due to the presence of a subcutaneous hematoma. The neurological examination revealed incomplete L5 paraplegia. Standard x-rays revealed L5-S1 spondylolisthesis and fracture of the L5 spinous process as well as fractures of the L3, L4, and L5 transverse processes. Computed tomography disclosed biarticular L5-S1 fracture dislocation and a voluminous herniation of the L5-S1 disc. Emergency surgery was performed and revealed subaponeurotic detachment from T4 to S1 and bald iliac pyramids. After L5 laminectomy and extraction of the voluminous herniation of the L5-S1 disc, a short L5-S1 posteriolateral fusion was achieved using pedicular screws and two rods on either side as well as a posterolateral iliac autograft. The clinical course was satisfactory with nearly complete neurological recovery (persistent levator ani paresis). This clinical case and a review of the literature illustrate the pathogenic, clinical, radiological and therapeutic aspects of lumbosacral fracture dislocation.

False penile fracture: report of 16 cases

We determined the value of diagnostic and therapeutic approaches of false penile fractures and the outcome of treatment. We retrospectively reviewed 16 cases of presumed penile fracture with a negative surgical exploration. Clinical presentation, technique of treatment and outcome were noted. The mean age was 39 years (17-64). Nine patients were injured during sexual intercourse. All the patients presented with the presumptive diagnosis of penile fracture. False penile fracture was evoked in one patient presenting a new erection. Surgical penile exploration was carried out for all the patients without any radiological explorations. It revealed nonspecific dartos bleeding in 10 cases and avulsed superficial dorsal vein in six cases requiring venous ends ligation. All the patients regained penile appearance and potency. We can hardly distinguish false penile fracture from 'true' penile fracture with certainty either clinically or radiologically, thus, surgical exploration is mostly necessary. The prognosis is excellent.

A child with raccoon eyes masquerading as trauma

Raccoon eyes are easily recognized and generally believed to be a common symptom of basal skull fractures. However, it may be a sign of some health threatening situations such as amyloidosis, Kaposi's sarcoma, multiple myeloma, and neuroblastoma. In this case, we present an infant with the final diagnosis of neuroblastoma who presented with raccoon eyes and was initially suspected of being a victim of child abuse. The exact diagnosis of this condition is sometimes delayed because of the workup for child abuse or trauma as occurred in the present case. Consequently, in order to avoid this conflict and possible delay of diagnosis and treatment, raccoon eyes should be considered meticulously and one should not be prejudiced until he / she reaches the exact diagnosis. We are presenting this well-known but interesting case in order to attract attention in this important issue once again.

Indirect traumatic optic neuropathy--retrospective interventional case series from a tertiary care center in eastern Nepal

To report the demography, nature of insult and ocular characteristics in patients presenting with indirect traumatic optic neuropathy and to evaluate the visual outcome with mega dose methylprednisolone therapy. Retrospective hospital data analysis of all patients admitted with indirect traumatic optic neuropathy and treated with mega dose methylprednisolone therapy in the last three years was conducted. Nine patients (M:F= 8:1) were identified with unilateral optic nerve injury. Road traffic injury was the most common cause of injury. Lid ecchymosis and swelling on the same side was the most frequent ocular abnormality noted, followed by loss of consciousness. Time of presentation varied from 3 hours to 11 days. All patients except two had visual acuity of no light perception at presentation. Following therapy there was improvement in visual acuity in two patients who presented within two days of injury. Patients present late with traumatic optic neuropathy in this hospital. Most of the patients are with no light perception. High dose steroids was found to be beneficial only in patients presenting early (<two days).

Penile fracture presenting as eggplant deformity

Penile fracture is caused by sudden trauma to erect penis leading to tear of corpora cavernosa. Although penile fracture is a rare condition, it can lead to crippling penile deformity and erectile impotence, if intervention is delayed. We describe a case of penile fracture caused by masturbation and satisfactory outcome after early surgical intervention. Usually only clinical assessment is sufficient for diagnosis.

Bilateral eyelid ecchymoses and corneal crystals: an unusual presentation of multiple myeloma

PURPOSE

This report describes a case of multiple myeloma that presented as bilateral eyelid ecchymoses and corneal crystals in the absence of widespread signs of systemic disease.

METHODS

A 55-year-old man was found to have the sudden appearance of bilateral eyelid ecchymoses after he flexed 90 degrees at the waist. On examination, amyloid deposition was found in the area of the lid ecchymoses, and corneal crystals were dispersed centrally and peripherally throughout all levels of the cornea on slit lamp examination. Urinalysis revealed Bence-Jones proteins and free kappa light chains. Bone marrow plasmacytosis suggested multiple myeloma.

RESULT

Ophthalmic and systemic findings led to a workup, which resulted in a diagnosis of multiple myeloma.

CONCLUSION

Our case demonstrates that multiple myeloma may present clinically with ophthalmic findings such as bilateral eyelid ecchymoses and corneal crystals in the absence of widespread signs of disease. The ocular findings may be the first manifestations of disease. Therefore, a systemic workup should be performed on patients with this presentation, including urine and bone marrow analyses.

Periorbital ecchymosis as a sign of perforating injury of the globe

The distinction between penetrating eye injury with retained intraocular foreign body and perforating globe injuries is not always easy clinically. The case is presented of a 25-year-old man who sustained a perforating eye injury that was through a clear self-sealing corneal entry site and had no conjunctival or periorbital injury. He had periorbital ecchymosis on presentation suggesting that the globe had been perforated with resulting retro-orbital blood tracking to the periorbital region. This sign would not be expected had the foreign body remained intraocular. The management options of these cases are discussed.

Infectious mononucleosis, ruptured spleen and Cullen's sign

Images

[My child bleeds easily: clinical and paraclinical approach]

The aim of this review article is to provide a clinical guideline for the child presenting with easy bruising, distinguishing among the different etiologic groups associated with this symptom what is normal and what is not, allowing then to establish an algorithm for work-up and follow-up. We also precise in which concrete situation it would be necessary to refer the child to a pediatric hematologist.

[Painful bruising syndrome mimicking cellulitis of the leg]

BACKGROUND

Autoerythrocyte sensitization syndrome (painful bruising syndrome) is marked by spontaneous and painful ecchymotic bruising, without any biological abnormality, occurring in women with pathological mental profile. Sometimes, when the inflammation is severe, an infectious cellulitis or muscular compression may be suspected.

CASE REPORT

A 21-year-old woman was referred for the rapid occurrence of a diffuse and painful inflammation of the right leg, with fever. The leg was red, warm, with diffuse bruising. The foot was fixed in varus equin. The biological parameters were normal. Magnetic resonance imaging showed normal muscles but modifications in the subcutaneous fat, similar to an acute cellulitis. A cutaneous biopsy showed a moderate oedema of the dermis and erythrocyte extravasation. Antibiotics were inefficient on the pain and the aspect of the lesions. Because of the efficacy of saline serum injections on the symptoms and a pathological psychological profile, an autoerythrocyte sensitization syndrome was suspected. The skin test was negative. Psychiatric evaluation revealed a severe personality disorder associated with depression. The ecchymotic lesions disappeared with adapted psychiatric treatment.

DISCUSSION

Painful bruising syndrome occurs most often in young women with various psychiatric problems. The lesions are characterized by recurrent, painful, swollen and bleeding bruises in any part of the body. Fever, abdominal pain and external bleeding are possible. Haematological and immunological findings are usually normal. The histology of early lesions reveals oedema of the dermis and modest perivascular infiltrate, whereas extravasated erythrocytes appear later. The magnetic resonance imaging aspect of the lesions has never been described. Abnormalities of the subcutaneous fat are similar to those of acute cellulitis, expressing the inflammation process secondary to the ecchymoses. The syndrome results from complex somatic and psychological mechanisms. Many drugs were tried for the treatment of the disease, without any significant improvement.

Facial features of widespread neuroblastoma: a case report

A case report of stage IV neuroblastoma which presented with periorbital swelling and ecchymosis originally misdiagnosed as facial trauma. The child soon developed a sinister pancytopenia, which following extensive investigations was revealed to be due to an underlying neuroblastoma. Periorbital ecchymosis associated with neuroblastoma is termed 'raccoon eyes' and is a diagnostic trap for the unwary.