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CASE IMAGE
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 203-204

Infantile hemangioma treated with systemic propranolol


Department of Skin and VD, SBKS MI and RC, Vadodara, Gujarat, India

Date of Submission09-Jun-2021
Date of Decision08-Jul-2021
Date of Acceptance09-Aug-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. Disha Sanjay Baxi
Room No. 56, Vama Girls Hostel, Sumandeep Vidyapeeth University, Pipariya, Vadodara - 391 760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_175_21

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How to cite this article:
Mahajan RS, Baxi DS. Infantile hemangioma treated with systemic propranolol. Indian Pediatr Case Rep 2021;1:203-4

How to cite this URL:
Mahajan RS, Baxi DS. Infantile hemangioma treated with systemic propranolol. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Sep 26];1:203-4. Available from: http://www.ipcares.org/text.asp?2021/1/3/203/325085

Infantile hemangiomas (IHs) are benign vascular tumors of infancy and childhood with unique clinical and histopathologic features[1]. They appear in the first weeks or months of life and display a characteristic natural history; rapid growth in the first 1–3 months followed by gradual involution. Tissue biopsies are positive for immunohistochemical staining with erythrocyte-type glucose transporter protein and other biomarkers specific for IH. The classification is according to soft-tissue depth (superficial, deep, and combined) and pattern of anatomic involvement (localized, segmental, multifocal, and indeterminate). The prevalence is reportedly 0.1% to 0.3%[2]. Most IHs are small and innocuous, resolve spontaneously, and require no treatment. However, a small proportion are considered potentially problematic. These include lesions that may result in scarring and disfigurement (e.g., facial), hepatic or airway IHs, and lesions which cause functional impairment (e.g., periorbital), ulceration, and are associated with vascular abnormalities within the cranium or in the aortic arch.

A 9-month-old healthy boy presented with a single, large (10 cm × 10 cm) vascular lesion extending over the right temporal scalp, and pre- and postauricular area [Figure 1]a. Although it had been present since birth, the parents had become concerned due to the recent episodes of bleeding and formation of raw areas on the surface of the lesion. Examination of the morphological features led us to make a diagnosis of a deep, segmented IH. The level of risk was considered high due to the presence of ulceration and disfigurement[1]. The location on the face and large size was an indication for neuroimaging. Magnetic resonance imaging of the brain revealed extracalvarial altered signal intensity lesion with few tortuous voids and a dilated tortuous feeding artery entering the lesion [Figure 2]a and [Figure 2]b.
Figure 1: (a) Large infantile hemangioma with oozing, bleeding, and crusting (b) Regression of the plaque with a decrease in vascularity at 12 weeks

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Figure 2: Magnetic resonance imaging brain (T2+ contrast and fluid-attenuated inversion recovery sequence) showing a few tortuous voids (A) and a dilated tortuous feeding artery (B) entering the lesion

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As per the international recommendations, and since the infant had no respiratory or cardiovascular contraindications[1], he was started on systemic propranolol. The hypothesized mechanism of action of propranolol is inhibition of vasodilation via beta-receptors. This causes vasoconstriction, reduces capillary blood flow, induces apoptosis in the endothelial cells, and results in regression of the tumor[3],[4]. The infant was initially primed with Prednisolone for 2 weeks. When compared with propranolol without steroids, this strategy has been shown to demonstrate superior reduction in size in the early stages, though the ultimate resolution of size at 6 months is similar. Management is usually started in early infancy. Oral propranolol was started as per recommendations (initially 1 mg/kg/day with meals and increasing it to 2 mg/kg/day) after ensuring baseline cardiac investigations were normal. The infant was kept in close follow-up and monitored for common complications (hypoglycemia, bradycardia, hypotension, and bronchospasm). The initial plan was to continue for at least 6 months or till regression of the lesion, whichever earlier. The lesion regressed within 4 months without any complications [Figure 1]b. The child is still in follow-up for occurrence of rebound lesions. Parents have been counseled and told to seek an opinion for laser surgery for the residual lesion by 5 years of age if the residual lesion still persists.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical practice guideline for the management of infantile hemangiomas. Pediatrics 2019;143:e20183475.  Back to cited text no. 1
    
2.
Mendiratta V, Jabeen M. Infantile hemangioma: An update. Indian J Dermatol Venereol Leprol 2010;76:469-75.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Nguyen HP, Pickrell BB, Wright TS. Beta-blockers as therapy for infantile hemangiomas. Semin Plast Surg 2014;28:87-90.  Back to cited text no. 3
    
4.
Sans V, de la Roque ED, Berge J, et al. Propranolol for severe infantile hemangiomas: Follow-up report. Pediatrics 2009;124:e423-31.  Back to cited text no. 4
    


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