Images in Emergency Medicine
Article Outline
A previously healthy 4-year-old child was presented because of refusal to eat or drink. No vomiting, fever, or diarrhea was reported by the parents. Examination revealed a normally behaving afebrile child with no signs of dehydration or sepsis. Multiple “impetigenized” lesions were noted on his face (Figure 1). The initial diagnosis of impetigo was cast into doubt after more lesions were revealed on patient's back and limbs. All lesions were regular in size and round, some had vesicular appearance, and others were more erythematous and raised (Figure 2). Child protective services were called.
Figure 1.
Multiple facial lesions.
Figure 2.
Different types of burns on patient's back.
Diagnosis
Child abuse caused by cigarette burns
The patient's mother admitted that she had purposely inflicted cigarette burns to here child. Cigarette burns are a major diagnostic problem.1 Burns located on a child's back or buttocks are unlikely to have been caused nondeliberately and therefore are more suspect than burns about the face and eyes, which can occur accidentally if the child runs into a lighted cigarette held by an adult.1, 2 Multiple lesions caused by cigarette burns are distinctively suggestive of child abuse, especially if they are of uniform size, circular, and showing groupings on the face, back, or limbs.1, 2 A typical lesion has a diameter of 0.5 to 0.8 cm and a well-defined smooth edge (Figure 3). Lesions in various stages of healing may be misdiagnosed as staphylococcal bullous impetigo or varicella virus infection.3 These cases are probably underreported because of low index of suspicion. A missed diagnosis can result in inappropriate medical care, ongoing abuse, and future fatality.2, 4
Figure 3.
Burn. The cigarette in the picture was used to compare diameters. Used with permission of Itai Shavit, MD, Emergency Department, Meyer Children's Hospital, Rambam Health Care Campus, Haifa, Israel.
References
- . Diagnosing physical child abuse: the way forward. Postgrad Med J. 2000;76:743–749
- Pattern of burns in child abuse. Am Surg. 2007;73:253–255
- . Staphylococcal scalded skin syndrome mimicking child abuse by burning. Forensic Sci Int. 2007;168:e1–e4
- Intentional burn injury: an evidence-based, clinical and forensic review. Burns. 2004;30:628–642
For the diagnosis and teaching points, see page 582.
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PII: S0196-0644(07)01441-2
doi:10.1016/j.annemergmed.2007.08.012
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
