A 4-month-old boy is brought to the office by his mother for a routine examination. This is the patient's first visit as the mother recently moved to the area. Review of medical records shows that the only parental concerns at age 2 months were excessive gassiness and spitting up, both of which have resolved. The patient was born full term and has no chronic medical conditions. Vaccinations are up to date. His parents recently divorced, and he now lives with his mother and 9-year-old sister. The sister has attention-deficit hyperactivity disorder and anxiety. The patient's height and weight are at the 50th and 75th percentiles, respectively. On physical examination, he is smiling and reaching for the examiner's stethoscope. He holds his bottle for a few seconds and then drops it on the ground. The patient can sit with support and roll from front to back. Flat, nonblanching, nontender patches over his sacrum and buttocks are shown in the image below. Which of the following is the most appropriate next step in management of this patient?

Question

A 4-month-old boy is brought to the office by his mother for a routine examination.  This is the patient's first visit as the mother recently moved to the area.  Review of medical records shows that the only parental concerns at age 2 months were excessive gassiness and spitting up, both of which have resolved.  The patient was born full term and has no chronic medical conditions.  Vaccinations are up to date.  His parents recently divorced, and he now lives with his mother and 9-year-old sister.  The sister has attention-deficit hyperactivity disorder and anxiety.  The patient's height and weight are at the 50th and 75th percentiles, respectively.  On physical examination, he is smiling and reaching for the examiner's stethoscope.  He holds his bottle for a few seconds and then drops it on the ground.  The patient can sit with support and roll from front to back.  Flat, nonblanching, nontender patches over his sacrum and buttocks are shown in the image below.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Congenital dermal melanocytosis (CDM, previously known as "Mongolian spots") presents as benign, flat, blue-gray patches that are usually found in infants over the lower back and buttocks. As the name suggests, the macules are caused by the presence of melanocytes within the skin's dermis. Most infants of African, Asian, and Hispanic ethnicity have CDM at birth. No treatment is required as the hyperpigmentation usually fades spontaneously during the first decade of life. CDM should be documented as these patches can be mistaken for bruises, potentially raising concern for coagulopathy or child abuse. (Choices A and E) Unexplained bruising or bleeding (eg, epistaxis, hematuria) warrants a complete blood count and coagulation studies to evaluate for a potential underlying bleeding disorder. Social stressors (eg, divorce, chronic illness) increase the risk of abuse, and skeletal survey would be indicated for signs of intentional injury (eg, patterned bruising). However, bruises are usually tender, varied in color, and fade quickly. In this case, the distribution and coloration make CDM the most likely diagnosis. (Choice B) MRI of the brain may be indicated for suspicion of neurocutaneous syndromes, such as neurofibromatosis. This disease is associated with optic gliomas and may present with café-au-lait macules, which are hyperpigmented (brown) patches. CDM is not associated with intracranial abnormalities, and imaging is not indicated. café-au-lait macules (Choice D) Cutaneous stigmata of occult spinal cord malformations include sacral dimples and hair tufts. CDM is not associated with spinal dysraphism, and sacral ultrasound is not warranted. sacral dimples Educational objective: Congenital dermal melanocytosis is commonly found in African, Asian, and Hispanic infants and presents as gray-blue macules, most commonly on the sacrum and buttocks. The spots usually fade spontaneously during childhood. References: Mongolian spots. (http://www.ncbi.nlm.nih.gov/pubmed/23760316) Common skin conditions in children: neonatal skin lesions. (http://www.ncbi.nlm.nih.gov/pubmed/28196316)

A 4-Month-Old Boy Is Brought to the Office by His