Cases of subcutaneous fat necrosis of the newborn (SCFN) and neonatal cold panniculitis have been reported most often secondary to perinatal distress or hypothermia. We present a case of a newborn infant who developed erythematous, indurated plaques on both cheeks and right shoulder following ice pack application for supraventricular tachycardia. The distinction between SCFN and cold panniculitis is important as SCFN may have complications such as hypercalcemia, whereas cold panniculitis is not associated with such sequelae. Clinicians should be aware of the diagnostic similarities and differences between these two conditions because of differences in potential serious sequelae.
The patient was a nine pound and 13 ounce girl born at 38 weeks gestation by induced vaginal delivery secondary to maternal history of large term infants. The pregnancy was significant for baseline hypothyroidism in the mother, but the delivery was otherwise uncomplicated. On the first day of life, the patient experienced supraventricular tachycardia. She was initially treated with ice bag application to her cheeks for approximately 10 minutes during the initial attempt at cardioversion (to increase vagal tone). She eventually required cardioversion with intravenous adenosine and the initiation of oral beta-blockers. On the second day of life, the patient developed erythematous, indurated plaques on her left and right cheeks as well as her right anterior shoulder (Figure 1). By the sixth day of life, the plaques were less erythematous but remained indurated. No epidermal changes were noted. She was active and had been feeding, stooling and voiding well. No seizures or spasms were noted. Punch biopsy from the right upper arm revealed a lobular panniculitis with a few cleft-like spaces present in the histiocytes (Figure 2). Needle-like crystals were not prominent. Baseline calcium levels were within normal limits.
The infant was followed clinically, and serum calcium levels were measured every 2 weeks. At 10 weeks of age, she showed normal development, and her skin was completely healed without residual scarring, atrophy or textural change. Serial ionized calcium measurements were normal (less than 5.2 mg/dl) until 10 weeks of age when one measurement was found to be slightly elevated at 5.6 mg/dl. Subsequent calcium levels were within normal limits until 6 months of age.
Subcutaneous fat necrosis of the newborn (SCFN)1, 2, 3, 4, 5, 6, 7 is a self-limited panniculitis usually occurring within the first few weeks of life in full-term infants.1, 5 Although the exact cause of SCFN is unknown, maternal and perinatal factors have been implicated, including maternal diabetes and pre-eclampsia, birth asphyxia and hypoxia, hypothermia and hypoglycemia.4, 7, 8 Generally, infants present with erythematous, indurated plaques most commonly on the cheeks, buttocks, posterior trunk and extremities. Histologic examination of SCFN lesions reveals a lobular or septal panniculitis with infiltration of lymphocytes, monocytes and multinucleated giant cells.4 Radially arranged needle-shaped clefts are present in lipocytes, but are not essential for the diagnosis.4, 5, 7 SCFN is usually self-limited and resolves within a few weeks to months without scarring.5, 7 However, rare systemic complications including thrombocytopenia, hypoglycemia, hypertriglceridemia and hypercalcemia can occur. Thrombocytopenia, hypoglycemia and hypertriglyceridemia are usually transient and resolve spontaneously or with minimal treatment. Hypercalcemia, the most serious potential complication, carries a risk of intellectual impairment, calcification of soft tissues, seizures, cardiac arrest, renal failure and death. Hypercalcemia may not manifest until 1 to 6 months after the lesions resolve.7 Calcium levels should be checked periodically. Treatment, if required, is frequently with pamidronate (0.5 to 2.0 mg/kg) and generally done in consultation with pediatric endocrine specialists.
Major differential diagnoses of SCFN include sclerema neonatorum and cold panniculitis. Sclerema neonatorum is a serious and often fatal condition characterized by diffuse hardening of the subcutaneous tissue in the first days of life. No evidence of fat necrosis or panniculitis is evident on biopsy.4 A more benign entity known as cold panniculitis has been described in infants exposed to cold weather, infants who have had ice applied to the skin, and in children who suck on cold objects (‘popsicle panniculitis’).9, 10, 11, 12, 13, 14 Like SCFN, cold panniculitis presents with erythematous indurated plaques, and younger children seem to be more susceptible to the effects of cold.14 In fact, Duncan et al.9 describe a case of cold panniculitis in a 6-month-old boy, who did not develop lesions when he was rechallenged with the same stimulus at 18 months of age. Lesions of cold panniculitis tend to be reproducible with repeated exposure in susceptible infants and usually appear within 48–72 h.5, 12 In biopsy specimens, inflammatory cells are usually found at the dermal/subcutaneous junction.4, 14 Serial histopathologic studies illustrate the inflammatory reaction intensifies over 48–72 h with resolution over 2 weeks.9 Lesions of cold panniculitis resolve spontaneously with no sequelae.10
Our patient had clinical features consistent with both SCFN and cold panniculitis. Craig et al.15 describe a similar case of a 14-day-old infant developing indurated erythematous plaques 24 hours after he was treated with ice bags to the face for termination of supraventricular tachycardia. A clinical diagnosis of cold panniculitis was made, but the authors did not comment regarding whether a biopsy was performed.15
In our patient, the histology was more typical of subcutaneous fat necrosis. Even though the characteristic crystals were inconspicuous, the inflammatory infiltrate involved the entire lobule. Silverman et al.5 describe a case where application of ice packs to induce hypothermia before cardiac surgery caused SCFN; the biopsy showed necrosis and inflammation of the full-thickness of the subcutis without evidence of crystalline structures. Wiadrowski and Marshmann6 also describe a case of an infant who underwent surface cooling to treat birth asphyxia. The initial clinical picture was consistent with cold panniculitis, but the condition evolved over the next several days resulting in a diagnosis of SCFN, which was confirmed both clinically and histologically.6
Although cold panniculitis must be considered in light of our patient's clinical history, the histological findings are more consistent with SCFN. It is important for clinicians to distinguish between cold panniculitis and SCFN because patients with SCFN should be monitored for hypercalcemia.
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Diamantis, S., Bastek, T., Groben, P. et al. Subcutaneous fat necrosis in a newborn following icebag application for treatment of supraventricular tachycardia. J Perinatol 26, 518–520 (2006). https://doi.org/10.1038/sj.jp.7211549
- cold panniculitis
- sclerema neonatorum
- subcutaneous fat necrosis
Subcutaneous fat necrosis and severe hypercalcemia as a complication of therapeutic hypothermia in a newborn with asphyxia
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