A Young Cuban Bruiser

A 7-year-old boy presents with unexplained bruising, a potential sign of malignancy.

Let's proceed with a thorough medical history.

The young boy was well until 4 days prior to evaluation, when bruises began to appear.

No past bruising, nosebleeds; change in platelets from 45,000 ~4-5 days ago to 245,000--CBC normal. Vitals, WNL; active, well nourished.

PMH non-contributory.

Note linear hyperpigmentation without petechiae or purpura; no hepatosplenomegaly.

Not bruising; rather discolored linear and whorled hyperpigmentation including denuded area (arrow) that resembles a burn.

Linear hyperpigmentation on forearms; oddly shaped discoloration on the abdomen.

This is not leukemia; "bruising" pattern appears as though skin has been smeared with something.

Lesion pattern on abdomen appears to be a hand print?

Are there fruit trees near the home? What kind? Do children play with the fruit?

Lime juice smeared on the skin that leaves a mark could be identified as: a drug reaction; a yet-to-be-determined hematologic disorder; phytophotodermatits.

Diagnosis: phytophotodermatitis.

Furocoumarins (psoralens), present in wide variety of plants react with sunlight, causing a photosensitive reaction.

A wide variety of plants contain psoralens.

The next case was initially suspected to be one of child abuse.

A young boy presents for evaluation of unexplained burns; child protection team was called.

Immediately suspicious for lime juice or other psoralen-rich substance.

Mother had handled child numerous times while preparing pie made with limes.

Erythema at first appears unusual.

Re-enactment of the mother's recent behavior with the child demonstrates a perfect match. Another case of phytophotodermatitis related to limes!

Time to brush up with a look back at your Hurwitz Textbook of Pediatric Dermatology?