Hemangioma
Ten year old girl brought with bleeding lips.
Past history of similar episodes of bleeding from lips. First impression with this history is Rendu osler weber syndrome .We had few cases of lesions on tongue, lips, finger tips associated with repeated hemoptysis.
In her case parents detected swelling lips and lower half of face since four months of age, which grew for two years and later regressed.
We searched for lesions in other parts of body
No bleeding or lesions from nose ,gums.
No hemetemesis ,malena, hematuria.
No head ache seizures& Fundus examination was normal
O/E.
Intelligent girl ,well grown .Vitals stable, No neuro cutaneous markers.
No other swellings apart from what is seen in the photographs (Lower lips and below left chin . Few different type of lesions verrucous were seen on the tongue both on the front and dorsal aspects.
System examination
within normal limits. No bruits over internal organs , and over skull .
Few learning points
Even when there is no obvious lesions visible on general examination we should be considering internal lesions and their indirect evidences.
Most important clinical signs in such a case are
1 High volume /collapsing pulse
2 Central cyanosis in the absence of any finding directly attributable in the CVS and Respiratory system examination
3. and auscultate over lung for continuous murmur in unusual locations
4. Occasionally there evidence of thrombocytopenia
5. Congestive failure high output type
Out of the lesions in the internal organs Pulmonary lesions are most important and they may be silent
One more very interesting but rare finding supporting this entity is looking for Orthodeoxia oxygen saturation difference related with position .
One simple non invasive test which may help in this scenario is Contrast ECHO .( injection of tritiated saline to a vein closest to the heart and check the time taken for the bubbles to come back to the left side.
Few learning points
Even when there is no obvious lesions visible on general examination we should be considering internal lesions and their indirect evidences.
Most important clinical signs in such a case are
1 High volume /collapsing pulse
2 Central cyanosis in the absence of any finding directly attributable in the CVS and Respiratory system examination
3. and auscultate over lung for continuous murmur in unusual locations
4. Occasionally there evidence of thrombocytopenia
5. Congestive failure high output type
Out of the lesions in the internal organs Pulmonary lesions are most important and they may be silent
One more very interesting but rare finding supporting this entity is looking for Orthodeoxia oxygen saturation difference related with position .
One simple non invasive test which may help in this scenario is Contrast ECHO .( injection of tritiated saline to a vein closest to the heart and check the time taken for the bubbles to come back to the left side.
But on looking at the lesions there are few atypical features which are not seen in Rendu osler weber or a usual hemangioma.
Verrucous lesions over the tongue ?
How common is it as part of hemangioma?
Few case reports of verrucous hemangiomas. But this location is uncommon
Investigations
Blood counts, platelets normalOpthalmological work up within normal limits
Planning CT angiogram
She is on propranalol now . just a trial
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