CASE REPORT
A 3-month-old female patient presented a red-wine colored macular lesion at birth in the right preauricular region of 1 cm, which progressively increased volume and size.
A month before admission (January 2019), the patient was evaluated by the dermatology department, that indicate a biopsy that evidence the presence of the hemangioma (Figure 1). A soft tissue ultrasound showed evidence compatible with an extensive submandibular glandular hemangioma with high-flow arterial compromise and high resistance, in addition to multiple arteriovenous shunts.
The hemangioma continued to grow, and the patient presented episodes of demanding dry cough and nasal discharge one week before being admitted to the hospital. She received treatment with antipyretics and antibiotics for five days. Two days before admission, the hemangioma continued to increase in volume and size, and the patient experienced shortness of breath during sleep with deep inspiration, cough associated with difficulty in breastfeeding and feverish sensation for which she came to the emergency department at Belen Hospital in Trujillo, Peru.
Upon admission, the patient presented with mild respiratory distress at rest and difficulty during lactation. They described a 15cm long by 7.5cm wide hemangioma located in the submandibular, preauricular and right malar region (Figure 2) with purplish color, telangiectasias disseminated inside, not mobile nor painful on palpation. In addition, the presence of another 3 cm of diameter hemangioma at the midline of the upper third of the left hemithorax. Treatment with propranolol is started to decrease the size of the hemangioma.
A chest x-ray showed airway displacement, and the otorhinolaryngology service suggested endotracheal intubation, verifying displacement of the trachea. The patient is transferred to the ICU and is started in mechanical ventilation. She experienced a fever peak, so laboratory tests were requested, including blood and urine culture. A globular package is transfused due to a drop in hemoglobin and antibiotic treatment is started due to a pathological urine test.
During hospitalization, she presented a desaturation episode attributed to the mass effect produced by the hemangioma. On physical examination, a decrease in vesicular murmur is evident in the right hemithorax, expiratory wheezing, and subcrepits. Control x-ray showed evidence of a consolidation pattern in the right hemithorax. The patient started double antibiotic coverage, atenolol instead of propranolol and corticosteroid therapy.
On the fourth day of hospitalization, the patient presented cardiorespiratory arrest. Treatment with captopril is started orally due to increased blood pressure. Respiratory symptoms were clinically stationary but had progressive reduction of the hemangioma dimensions. On the ninth day, she presented a feverish peak and got switched to a broad-spectrum antibiotic coverage with gradual suspension of corticosteroid.
During the tenth day of hospitalization, the patient was extubated, tolerating spontaneous ventilation with mild stridor and aphonia, nebulized with adrenaline and restarting corticosteroid therapy. The patient was transferred to another hospital where she continued with antibiotic treatment, atenolol and captopril with favorable evolution and reduction of the hemangioma. She is discharged with oral antibiotic treatment and indication of outpatient center control.
The patient continues with the follow up in the other hospital until today, on May 2020 she does not have any complication or recurrence of the tumor.