Recurrent bloody stools associated with visceral infantile haemangioma in a preterm twin girl

Abstract

A premature twin infant girl was transferred to a level IV neonatal intensive care unit for recurrent bloody stools, anaemia and discomfort with feeds; without radiographic evidence of necrotising enterocolitis. Additional imaging after transfer revealed a large retroperitoneal mass in the region of the pancreas compressing the inferior vena cava and abdominal aorta, raising suspicion for neuroblastoma. Abdominal exploration and biopsy unexpectedly revealed that the lesion was an infantile capillary haemangioma involving the small bowel, omentum, mesentery and pancreas. The infant was subsequently treated with propranolol, with a decrease in the size of the lesion over the first year of her life and a drastic improvement in feeding tolerance. While cutaneous infantile haemangiomas are common, visceral infantile haemangiomas are less so and may present a significant diagnostic challenge for clinicians. This interesting case demonstrates that such lesions should be considered in the differential diagnosis for unexplained gastrointestinal bleeding or abdominal symptoms in newborns.

Keywords: neonatal intensive care; paediatric surgery.

Figure 1

Imaging of a visceral infantile haemangioma mimicking neuroblastoma in a 7-month-old female twin. Greyscale (A) and colour Doppler (B) ultrasound show a mildly hypoechoic, vascular solid mass within the head of the pancreas (white arrows). Axial (C) and sagittal (D) single-shot fast spin echo T2-weighted MR images (C) demonstrate a homogenous hypointense mass within the head of the pancreas (white arrows), in addition to ill-defined retroperitoneal tissue wrapping around the superior mesenteric artery (white arrowheads). Fused single-photon emission CT imaging using 123-iodine (123-I) metaiodobenzylguanidine (MIBG) in axial (E) and sagittal (F) planes shows vague radiotracer uptake in the retroperitoneum (white arrows) corresponding to the abnormal tissue found on ultrasound and MRI. Note the normal MIBG uptake in the heart (Ht). PHA, proper hepatic artery; PICC, peripherally inserted central catheter; SMA, superior mesenteric artery.

Figure 2

Intraoperative photographs of the visceral infantile haemangioma. (A) Erythematous nodule (haemangioma) abutting the head of the pancreas (white arrow) with diffuse erythematous nodularity noted on the bowel wall (black arrow). (B) Erythematous nodularity involving the omentum (black arrow) and small bowel (white arrow).

Figure 3

Immunohistochemical staining for glucose transporter-1 (GLUT-1) at (A) low power and (B) high power. (Histopathology courtesy of Cristina Pacheco, MD, Department of Pathology, Seattle Children’s Hospital, Seattle, Washington).