Abnormal “bruising” over the abdomen of a neonate

An asymptomatic 2-week-old girl presented to the emergency department with a 7-day history of faint, pink–red patches on her abdomen. On examination, the neonate had bilateral, symmetric, blanchable erythematous telangiectasias coalescing into a butterfly-shaped pattern over the lower abdomen (Figures 1 and 2). She had no current or prior history of abdominal distension. No other cutaneous findings, including ecchymoses, lacerations, or abdominal masses, were noted. She was otherwise healthy, born at term following a normal pregnancy. Her lab investigations including CBC, INR, liver enzymes, albumin, and LDH were unremarkable except for a slightly elevated bilirubin which was physiologic. Transient abdominal telangiectasia of the newborn (TATN) is a transient phenomenon, sometimes associated with abdominal distension in some neonates, which presents with radially arranged telangiectasias that coalesce into a butterfly wing-shaped pattern over the lower abdomen.1 It is not present at birth and patients present at a median age of 7 days after birth.1 It appears to be present evenly among male (55%) and female (45%) newborns.1 Mothers of patients with TATN usually have a normal, uncomplicated pregnancy. Most affected neonates have a normal clinical exam, but some have abdominal distension. A possible explanation for the connection to telangiectasia is that intraabdominal pressure can disrupt venous return and affect the skin microcirculation, leading to abdominal telangiectasias.1 Most lesions spontaneously resolve after 3 months of age and do not re-occur.1, 2 Our case presented with the characteristic telangiectasias of TATN at around 7 days of life without abdominal distension. Another possible explanation for this finding, which could account for patients without abdominal distension, is that it may be similar to other neonatal vascular phenomena due to immature autonomic functioning of vascular control, such as glabellar nevus simplex or Harlequin color change. A previous report in the literature described three cases of “self-limited neonatal periumbilical erythema”, which was thought to be related to umbilical stump detachment.2 No abdominal distension was reported in these cases. One of these patients, a 15-day-old boy had a faint reticular violaceous patch with blanching telangiectasias bilaterally on the abdomen adjacent to the umbilicus. Another 3-week-old healthy boy also presented with a similar lesion around 1.5 weeks of age. There were no signs of intra-or periumbilical infection in these cases, and the skin lesions resolved within 2 months of umbilical stump separation. There were no further recurrences of the telangiectasias. While the authors hypothesized that umbilical stump detachment resulted in cytokine release, triggering inflammation or vasodilation resulting in telangiectasias, the clinical presentation and natural history of these cases suggest that this report likely described TATN in these neonates as well. Although usually isolated, there has been one case of Hirschsprung's disease, and one case of rhabdomyosarcoma associated with TATN patients who had abdominal distension.1 The patient with rhabdomyosarcoma also presented with a palpable pelvic mass and bilateral edema of the proximal thighs. Most patients with TATN who have undergone abdominal ultrasonography had unremarkable findings. Recurrence of TATN is rare and in a case series of 20 patients, only one had recurrence associated with episodes of abdominal distension, with the lesions being much less prominent on recurrence as compared to the initial presentation.1 Other than TATN, several other conditions should be considered in the differential diagnosis for periumbilical skin lesions in newborns. This includes cellulitis and omphalitis.3 However, these usually present with purulent umbilical discharge, abdominal tenderness, and/or fever. Rarely, umbilical artery catheterization can result in reticular periumbilical erythema.4 Infantile hemangiomas with minimal or arrested growth are usually present on the lower limbs as bright red, fine, or coarse telangiectatic patches but do not fade away this quickly.5 Cutis marmorata telangiectatica congenita, hereditary benign telangiectasia, ataxia telangiectasia, hereditary hemorrhagic telangiectasia, and Bloom syndrome are some other congenital/hereditary disorders associated with telangiectasias in infancy.6, 7 However, the non-congenital nature, bilateral symmetric distribution, and the absence of vasoconstrictive halos, arteriovenous malformations, and neurological symptoms rule out these alternative diagnoses in our patient. TATN can be suspected by the characteristic abdominal telangiectatic distribution in otherwise asymptomatic infants. If abdominal distension is present, abdominal ultrasonography should be performed to rule out any associated underlying conditions. Since TATN is usually isolated and self-limited, further testing and workup are unnecessary in the absence of abdominal distension. Healthcare providers can offer reassurance to families and follow up accordingly to ensure the resolution of this benign condition. The authors declare no conflict of interest.

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