Journal of Perinatology (2006) 26, 518–520 r 2006 Nature Publishing Group All rights reserved. 0743-8346/06 $30 www.nature.com/jp PERINATAL/NEONATAL CASE PRESENTATION Subcutaneous fat necrosis in a newborn following icebag application for treatment of supraventricular tachycardia S Diamantis1, T Bastek2, P Groben3 and D Morrell3 1Mount Sinai Hospital, Mount Sinai School of Medicine, New York, NY, USA; 2Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA and 3Department of Dermatology, University of North Carolina, Chapel Hill, NC, USA in the histiocytes (Figure 2). Needle-like crystals were not Cases of subcutaneous fat necrosis of the newborn (SCFN) and neonatal prominent. Baseline calcium levels were within normal limits. cold panniculitis have been reported most often secondary to perinatal The infant was followed clinically, and serum calcium levels distress or hypothermia. We present a case of a newborn infant who were measured every 2 weeks. At 10 weeks of age, she showed developed erythematous, indurated plaques on both cheeks and right normal development, and her skin was completely healed without shoulder following ice pack application for supraventricular tachycardia. residual scarring, atrophy or textural change. Serial ionized The distinction between SCFN and cold panniculitis is important as SCFN calcium measurements were normal (less than 5.2 mg/dl) until 10 may have complications such as hypercalcemia, whereas cold panniculitis weeks of age when one measurement was found to be slightly is not associated with such sequelae. Clinicians should be aware of the elevated at 5.6 mg/dl. Subsequent calcium levels were within diagnostic similarities and differences between these two conditions because normal limits until 6 months of age. of differences in potential serious sequelae. Journal of Perinatology (2006) 26, 518–520. doi:10.1038/sj.jp.7211549 Keywords: cold panniculitis; sclerema neonatorum; subcutaneous fat necrosis; newborn; SVT Discussion Subcutaneous fat necrosis of the newborn (SCFN)1–7 is a self- limited panniculitis usually occurring within the first few weeks of life in full-term infants.1,5 Although the exact cause of SCFN is Case report unknown, maternal and perinatal factors have been implicated, The patient was a nine pound and 13 ounce girl born at 38 weeks including maternal diabetes and pre-eclampsia, birth asphyxia and 4,7,8 gestation by induced vaginal delivery secondary to maternal history hypoxia, hypothermia and hypoglycemia. Generally, infants of large term infants. The pregnancy was significant for baseline present with erythematous, indurated plaques most commonly on hypothyroidism in the mother, but the delivery was otherwise the cheeks, buttocks, posterior trunk and extremities. Histologic uncomplicated. On the first day of life, the patient experienced examination of SCFN lesions reveals a lobular or septal supraventricular tachycardia. She was initially treated with ice bag panniculitis with infiltration of lymphocytes, monocytes and 4 application to her cheeks for approximately 10 minutes during the multinucleated giant cells. Radially arranged needle-shaped clefts 4,5,7 initial attempt at cardioversion (to increase vagal tone). She are present in lipocytes, but are not essential for the diagnosis. eventually required cardioversion with intravenous adenosine and SCFN is usually self-limited and resolves within a few weeks to 5,7 the initiation of oral beta-blockers. On the second day of life, the months without scarring. However, rare systemic complications patient developed erythematous, indurated plaques on her left and including thrombocytopenia, hypoglycemia, hypertriglceridemia right cheeks as well as her right anterior shoulder (Figure 1). By and hypercalcemia can occur. Thrombocytopenia, hypoglycemia the sixth day of life, the plaques were less erythematous but and hypertriglyceridemia are usually transient and resolve remained indurated. No epidermal changes were noted. She was spontaneously or with minimal treatment. Hypercalcemia, the most active and had been feeding, stooling and voiding well. No seizures serious potential complication, carries a risk of intellectual or spasms were noted. Punch biopsy from the right upper arm impairment, calcification of soft tissues, seizures, cardiac arrest, revealed a lobular panniculitis with a few cleft-like spaces present renal failure and death. Hypercalcemia may not manifest until 1 to 6 months after the lesions resolve.7 Calcium levels should be Correspondence: Dr D Morrell, Department of Dermatology, University of North Carolina, checked periodically. Treatment, if required, is frequently with 3100 Thurston-Bowles Building, Chapel Hill, NC 27599-7287, USA. E-mail: [email protected] pamidronate (0.5 to 2.0 mg/kg) and generally done in consultation Received 26 January 2006; revised 25 April 2006; accepted 5 May 2006 with pediatric endocrine specialists. Ice-induced newborn fat necrosis and SVT S Diamantis et al 519 Figure 1 Two-day-old infant with erythematous, indurated plaque on her left cheek. Her contralateral cheek as well as her right anterior shoulder was also involved. Major differential diagnoses of SCFN include sclerema neonatorum and cold panniculitis. Sclerema neonatorum is a serious and often fatal condition characterized by diffuse hardening of the subcutaneous tissue in the first days of life. No evidence of fat necrosis or panniculitis is evident on biopsy.4 A more benign entity known as cold panniculitis has been described in infants exposed to cold weather, infants who have had ice applied to the skin, and in children who suck on cold objects (‘popsicle panniculitis’).9–14 Like SCFN, cold panniculitis presents with erythematous indurated plaques, and younger children seem to be more susceptible to the effects of cold.14 In fact, Duncan et al.9 describe a case of cold panniculitis in a 6-month-old boy, who did not develop lesions when he was rechallenged with the same stimulus at 18 months of age. Lesions of cold panniculitis tend to be reproducible with repeated exposure in susceptible infants and usually appear within 48–72 h.5,12 In biopsy specimens, inflammatory cells are usually found at the dermal/subcutaneous junction.4,14 Serial histopathologic studies illustrate the inflammatory reaction intensifies over 48–72 h with resolution over 2 weeks.9 Lesions of cold panniculitis resolve spontaneously Figure 2 A low-power view reveals lobular panniculitis with sparing of with no sequelae.10 the dermis and epidermis (original magnification  20). In a high- Our patient had clinical features consistent with both SCFN and power view (lower panel), the inflammatory infiltrate is mixed and is cold panniculitis. Craig et al.15 describe a similar case of a 14-day- composed of histiocytes, lymphocytes, neutrophils and eosinophils. Cleft-like spaces (arrow) suggestive of dissolved crystals are noted at the old infant developing indurated erythematous plaques 24 hours periphery of some of the fat cysts (original magnification  400). after he was treated with ice bags to the face for termination of supraventricular tachycardia. A clinical diagnosis of cold panniculitis was made, but the authors did not comment regarding the biopsy showed necrosis and inflammation of the full-thickness whether a biopsy was performed.15 of the subcutis without evidence of crystalline structures. In our patient, the histology was more typical of subcutaneous Wiadrowski and Marshmann6 also describe a case of an infant who fat necrosis. Even though the characteristic crystals were underwent surface cooling to treat birth asphyxia. The initial inconspicuous, the inflammatory infiltrate involved the entire clinical picture was consistent with cold panniculitis, but the lobule. Silverman et al.5 describe a case where application of ice condition evolved over the next several days resulting in a diagnosis packs to induce hypothermia before cardiac surgery caused SCFN; of SCFN, which was confirmed both clinically and histologically.6 Journal of Perinatology Ice-induced newborn fat necrosis and SVT S Diamantis et al 520 Although cold panniculitis must be considered in light of our 6 Wiadrowski TP, Marshman G. Subcutaneous fat necrosis of the newborn patient’s clinical history, the histological findings are more following hypothermia and complicated by pain and hypercalcaemia. consistent with SCFN. It is important for clinicians to distinguish Australas J Dermatol 2001; 42: 207–210. between cold panniculitis and SCFN because patients with SCFN 7 Tran JT, Sheth AP. Complications of subcutaneous fat necrosis of the should be monitored for hypercalcemia. newborn: A case report and review of the literature. Pediatr Dermatol 2003; 20: 257–261. 8 Lee SK, Lee JH, Han CH, Ahn YM, Choi YS, Kim IO. Calcified subcutaneous fat necrosis induced by prolonged exposure to cold weather: A case report. Pediatr Radiol 2001; 31: 294–295. References 9 Duncan WC, Freeman RG, Heaton CL. Cold panniculitis. Arch Dermatol 1 Katz DA, Huerter C, Bogard P, Braddock SW. Subcutaneous fat necrosis of 1966; 94: 722–724. the newborn. Arch Dermatol 1984; 120: 1517–1518. 10 Rajkumar SV, Laude TA, Russo RM, Gururaj VJ. Popsicle panniculitis of the 2 Duhn R, Schoen EJ, Siu M. Subcutaneous fat necrosis with extensive cheeks. A diagnostic entity caused by sucking on cold objects. Clin Pediatr calcification after hypothermia in two newborn infants. Pediatrics 1968; 41: (Philadelphia) 1976; 15: 619–621. 661–664. 11 Baruchin AM, Scharf S. Cold panniculitis in children (haxthausen’s