Radiological case of the month.

A FULL-TERM INFANT had asphyxia at 1 day of age. His weight was 3500 g; his length, 49 cm; and his head circumference, 36 cm (all parameters were between the 50th and 75th percentiles). Apgar scores were 1 and 5 at 1 minute and 5 minutes, respectively. A tracheal intubation was performed because of asphyxia, bradycardia, and poor respiratory effort. The patient was treated with 12 hours of mechanical ventilation followed by continuous positive airway pressure ventilation for the next 3 days. Neonatal hypoglycemia was treated with intravenous dextrose, and metabolic acidosis with intravenous bicarbonate. The first day, seizures occurred lasting approximately 5 minutes. Dystonia, opisthotonos, and irritability were observed during the first week. Brain magnetic resonance imaging indicated frontal regions of encephalomalacia and blood surrounding the left cerebellar hemisphere. On day 2, pitting edema appeared on the back, and there were dusky, reddishpurple nodular lesions on the neck and back. The overlying skin was taut with violaceous coloration, and the lesions were sharply circumscribed with an irregular surface. The affected area of the back extended from the neck to the thoracolumbar junction (Figure 1). Magnetic resonance imaging of the lower cervical region and upper thorax was performed (Figure 2 ). The white blood cell count was 40000/μL during the first week, then decreased to 15000/μL. Polymorphonuclear leukocytes consistently made up 50% to 60% of the total number of white blood cells, and no nonsegmented polymorphonuclear cells were present. The erythrocyte sedimentation rate was 95 mm/h, and C-reactive protein reached a level of 9.3 mg/dL. Blood cultures and serologies were negative for toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex. An ultrasonographic evaluation showed no structural abnormalities of the kidneys or urinary tract. The skin lesions continued to enlarge for 2 weeks. When the patient was discharged at 2 months of age, the lesions had decreased to 60% of the former size.