A 1-month-old, full-term boy is brought to the emergency department by his mother due to difficulty awakening him. The mother says that the infant was left alone for a few minutes this morning and rolled off a bed. Since then, he has been sleepy and less active than usual. Physical examination shows a lethargic boy with a large, full anterior fontanelle. Bilateral retinal hemorrhages are seen on funduscopic examination. Which of the following should be strongly suspected in this patient?

Question

A 1-month-old, full-term boy is brought to the emergency department by his mother due to difficulty awakening him.  The mother says that the infant was left alone for a few minutes this morning and rolled off a bed.  Since then, he has been sleepy and less active than usual.  Physical examination shows a lethargic boy with a large, full anterior fontanelle.  Bilateral retinal hemorrhages are seen on funduscopic examination.  Which of the following should be strongly suspected in this patient?

Quizplus · Accepted Answer

11ec160b_39b5_f55e_9249_cd601530bdcc_MD0001_00 Abusive head trauma (AHT), formerly known as "shaken baby syndrome," is inflicted intracranial injury due to blunt force trauma or vigorous shaking in a to-and-fro fashion. The resultant injuries are due to infants' unique anatomic features. Infants have larger heads, enlarged subarachnoid spaces, higher brain water content, and decreased cervical muscle tone compared to older children. These factors lead to increased movement of the immature brain in relation to the skull, resulting in tearing of the bridging veins and subdural hemorrhages. Because AHT may occur repeatedly over weeks to months, acute on chronic subdural hemorrhages are often seen. The shaking motion also results in retinal hemorrhages due to rupture of congested retinal veins. Retinal hemorrhages are highly suggestive of AHT. Infants' ribs are flexible and pliable, and posterior rib fractures are also alarming for trauma by a perpetrator's grasp on the torso. In addition, the history provided by this patient's parent does not match his developmental age, as rolling over is not typical before age 4 months. Furthermore, an accidental fall (Choice F) from a bed would generally not be sufficient to cause a large intracranial hemorrhage resulting in altered mental status and would not explain retinal hemorrhages. (Choice B) Although bacterial meningitis can cause lethargy, patients are typically febrile. (Choice C) Idiopathic thrombocytopenic purpura, caused by platelet autoantibody formation, presents with petechiae, ecchymoses, and bleeding after minor trauma. Intracranial hemorrhage is rare and retinal hemorrhages are not seen. (Choice D) All newborns are vitamin K-deficient and are given prophylactic vitamin K injections at birth. Although vitamin K deficiency can present with intracranial, umbilical, and gastrointestinal bleeding, retinal hemorrhages are not seen. (Choice E) Retinoblastoma is the most common ocular tumor of infancy and presents with absence of the "red reflex" on physical examination. Lethargy and retinal hemorrhage are not seen. Educational objective: Abusive head trauma can be caused by vigorous shaking of an infant and results in subdural hemorrhage (due to tearing of bridging veins) and retinal hemorrhages. Additional red flags are injuries inconsistent with history or developmental age. __________ References: Abusive head trauma in children: a literature review. (http://www.ncbi.nlm.nih.gov/pubmed/23850113) Abusive head trauma: past, present, and future. (http://www.ncbi.nlm.nih.gov/pubmed/25316728) Aspects of abuse: abusive head trauma. (http://www.ncbi.nlm.nih.gov/pubmed/25771265)

A 1-Month-Old, Full-Term Boy Is Brought to the Emergency Department