CASE PRESENTATIONS

Brenda Mirabal MD
Child Abuse Pediatrician and Professor
Dept. of Pediatrics, MSC, UPR

CASE 1
3 months old male born prematurely at
32 weeks gestation to 22 y/o G2P2A0,
who received TPN for 4 weeks in NICU.
Remained in NICU until 2 days ago. Presents
with sudden onset of hypoactivity, vomiting,
poor p.o. intake and seizures. No hx of
fever. No other family members ill.
On PE on arrival, he was found lethargic,
bulging fontanelle and had several seizures.
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WORK UP
What labs would you order?
CBC with platelets, CMP, Blood culture, CRP,
urinalysis, spinal tap, urine culture (cath), PT,
PTT.

What studies would you order?

Head CT scan
CT scan shows interhemispheric subdural hematoma
and right epidural hematoma

Skeletal survey
Metaphyseal fracture of left radius, multiple rib
fractures (paravertebral and lateral), linear fracture
in Right temporal bone

Bone scan
Increased uptake in left lateral rib cage and right
paravertebral areas,
and in left radius
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CONSULTATIONS
Ophthalmology
Multiple retinal hemorrhages and preretinal hemorrhages in left
eye, to ora serrata, and some retinal hemorrhages in right eye

Social Work
Biopsychosocial Program

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IMAGES OF RETINAL HEMORRHAGES

AND SUBDURAL HEMATOMA

Retinal hemorrhages
From:http://dontshake.org/sbs.p
hp?
topNavID=3&subNavID=25&su
bnav_1=803&navID=807
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Left acute subdural

Hematoma. From:
http://emedicine.m
edscape.com/articl
e/247472-overview

WHAT IS THE DIFFERENTIAL

DIAGNOSIS?
Clinical Sepsis
ALTE
Seizure Disorder
Metabolic Disorder (Glutaric Acidemia,
Osteogenesis Imperfecta)
Rickets
Non intentional head trauma
Abusive Head Trauma
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WHAT IS YOUR DIAGNOSIS?

Abusive Head Trauma

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CASE 2
3 months old female born to a 22 y/o G4P4A0
who is brought to the ER with second degree
burns of 8% TBSA, involving lower abdomen,
genitalia, inner thighs, buttocks. There is a
demarcation line in lower back. Mother
refers that 2 hours ago, she placed infant in
sink and noticed the burns when she started
crying. Mother called her sister, who
brought the infant to the hospital.
She is a single mother, who lives in public
housing.

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WORK UP

1.Take a detailed history, including

the different versions, and
document each one in the medical
record.
2.Conduct a complete physical
exam, including genitalia and anus
3.Take photographs of burns
4.Order a skeletal survey
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IMMERSION BURNS

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FORENSIC INVESTIGATION
1. Take temperature of the running
water every 5 seconds until stable for
15 seconds (Max. temp= 110 F)
2. Interview the manufacturer of water
heater to certify temperature of
heater
3. Measure depth, length and width of
sink
4. Take photos of the setting
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DIFFERENTIAL DIAGNOSIS

1.Unintentional burn
2.Immersion burn, intentional

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WHAT IS YOUR DIAGNOSIS?

Immersion burn, intentional

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CASE 3
3 weeks old male born prematurely
at 35 weeks gestation, who is noticed
with respiratory difficulty and is
brought to ER. On exam, patient
irritable and chest x-ray shows no
pneumonia. However, is found with
multiple bilateral rib fractures.
Mother refers no history of trauma.
PE shows bluish sclerae; no joint
laxity.
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WORK UP
Labs
CBC with platelets (nl), PT, PTT
(both nl), Ca (nl) P (nl), Alk Phosph
(430), CMP (nl)
Skeletal survey
Multiple rib fractures
Bone scan
Multiple rib fractures
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FOLLOW UP
Patient is discharged and is readmitted 10
days later, when mother returned home and
father told her infants leg was swollen and
with decreased mobility
What labs/studies would you order?
Skeletal survey (no osteopenia, left femur
diaphysis fracture and right femur metaphyseal fx,
multiple rib fxs ( in different stages), spinous
process fxs (T5-T9)
Bone scan (multiple rib fxs and femoral lesions)
DNA for osteogenesis imperfecta
Findings do not confirm osteogenesis imperfecta
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RADIOGRAPHS OF CASE 3

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RADIOGRAPHS OF CASE 3

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FRACTURES SPECIFIC FOR PHYSICAL

ABUSE
Metaphyseal fractures (chip or bucket
handle fractures)
Paravertebral rib fractures
Spinous process fractures
Scapular fractures
Sternal fractures

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OSTEOGENESIS IMPERFECTA

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FOLLOW UP
Pt was followed up for two years, and
no other fractures or hospitalizations
occurred.
What was the final diagnosis?
Physical Abuse

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CASE 4
2 y/o female referred by Pediatrician for
suspected sexual abuse. Mother noticed
lesions in genital area since several weeks
ago. No other symptoms. Child has not
disclosed sexual abuse. There are no
allegations of abuse. No hx of vaginal
secretions, vaginal bleeding, rectal
bleeding or changes in behavior.
Physical exam is normal. Anogenital exam
was done with colposcope and lesions
were observed in vulva and hymen. No
hymenal or anal lacerations observed.
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ANOGENITAL EXAM POSITIONS (SHOULD

BE CONDUCTED IN MORE THAN ONE
POSITION)

frog leg, supine position

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POSITIONS

Knee chest position

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ALTERNATIVE POSITIONS

Frog leg position, on mothers

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FEMALE GENITALIA- CORRECT

TERMINOLOGY

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MALE GENITALIA- TERMINOLOGY

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LABIAL SEPARATION AND LABIAL

TRACTION

Labial separationseparate both labia

laterally

Labial traction- pull both

labia outward. It provides
better visualization.
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KNEE CHEST EXAM

Push backward and

outward
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DESCRIPTION OF FINDINGS

Frog-leg
position;
complete
hymenal
laceration at
6 oclock
Description of findings: position of exam,
position of findings relative to a clock .
Hymenal lacerations and loss of hymen from
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4 to 8 are consistent
with penetrating trauma

NORMAL GENITALIA (FROG-LEG

POSITION)

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NORMAL GENITALIA, KNEE CHEST

POSITION

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GENITAL LESION (CASE 4)

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WHAT IS YOUR DIAGNOSIS?

Dx:
Condyloma Acuminata (Human Papilloma
virus)
Is it always sexual abuse?
How is it transmitted?
How do you treat it?
Aldara cream
How do you prevent it?
Gardasil vaccine (9-26 years of age)
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CASE 5
6 year old female is brought to ER due
to R/O sexual abuse. Mother refers she
noticed child had vaginal bleeding this
morning for the first time. No vaginal
secretions. No changes in behavior.
Child has not disclosed sexual
molestation to mother or anyone.
The physical exam is normal except
for the genital area. Anus has normal
tone and rugae and no lacerations.
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WHAT IS YOUR DIAGNOSIS?

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Dx: Urethral

CASE 6
17 year old male comes to ER due to
a genital lesion that has been present
for about a week, and is not painful.
He denies sexual abuse. He has had
no sexual contact during the last
week. Upon further questioning, he
refers he had sexual contact with an
18 year old female he met at the bar,
about 3 weeks ago, once. He didnt
use a condom because he doesnt like
them.
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WHAT IS THE DIAGNOSIS?

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Dx: Syphilis

HOW DO YOU DIAGNOSE AND TREAT

SYPHILIS?
Diagnosis:
VDRL, RPR (screening test)
FTA-Absorption test (Confirmatory treponemal
test )

Benzathine Penicillin G 2.4 million units IM

(50,000 units/kg)
If allergic to Penicillin, and older than 8
years of age, use Doxycycline 100mg po bid
for 2 weeks.
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CASE 7
A 5 year old girl is brought to the Pediatrician
because she has become aggressive with her
siblings and plays inappropriately with her
siblings and her dolls. When asked to explain,
the mother refers that she kisses her 2 year old
sister in the mouth, the chest and touches her
genital area. She also has started to kiss her
father in the mouth, which she didnt do before.
The child told mother that abuelo me hace
eso. She started to have nightmares several
months ago, where she starts crying. Hx of 2
UTIs in the last six months, bedwetting (even
though she was toilet trained). No hx of vaginal
bleeding or secretions; no hx of rectal bleeding.
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CASE 7
Upon further questioning, mother
refers that she bathes her child and
has noticed that sometimes she
complains of burning when she
washes the genitalia. Nobody else
bathes her. The maternal grandfather
picks her up from the day care and
takes her to the grandparents house
until the mother picks her up in the
afternoon.
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COLPOSCOPY

Frog leg supine

Knee chest position
position
Genitalia:
exam in frog-leg and knee chest positions; normal labia
majora and minora, crescentic hymen with smooth border and no
lacerations, normal fossa navicularis and posterior fourchette.
Anus: normal tone and rugae,
no lacerations observed (no photos
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taken)

WORK UP
What labs would you do?
1.
2.
3.
4.
5.

VDRL, Hepatitis profile, HIV

Urine NAAT for gonorrhea and GC
Urinalysis
None of the above
All of the above

What else would you do?

Consult Social Work

Consult Biopsychosocial Program
Refer for specialized validation/forensic
interviewing services
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FOLLOW UP

During forensic interviewing,

the child said that maternal
grandfather used to kiss her in
the mouth, in her chest and
touch her genital area with his
fingers. It happened many times,
in the car and at his home.
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CASE 8
This is a 12 year old male who
comes to the ER due to suspected
sexual abuse. He refers that mi to
Toms, me meti el pip en el culo,
muchas veces, y me doli. Pas en
mi cuarto y en la casa de mi abuela.
El pip estaba duro y botaba algo
como leche, que apestaba.
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COLPOSCOPY

Genitalia: Normal circumcised

penis, no lesions or
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secretions, normal descended testes (not visualized)

COLPOSCOPY

Anus: exam in knee-chest position; flattened rugae, markedly

decreased anal tone and anal dilatation
(no feces in ampulla), no
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lacerations or scars

COLPOSCOPY (9 MONTHS LATER)

Anus: exam in knee-chest position; rugae visible and

markedly improved anal bmirabal-2014
tone when compared to
previous exam

CASE 9
13 year old girl who comes to the ER
after taking 15-20 Tylenol Extra Strength
tablets and 3 Atarax tabs.
She is
lethargic and vomited once.
Mother
refers it is the second time she has had a
suicide attempt. She has been skipping
class, and her academic performance has
deteriorated, with Ds and Fs. She is
also staying out late at night.
No previous hospitalizations except for
the suicide attempt one year ago.
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CASE 9
Physical exam shows a W/D, W/N adolescent
who looks sad and withdrawn. She doesnt want to
talk. She refers she broke up with her boyfriend.
She is hostile towards mother.
What else would you ask?
Hx of drug, alcohol or cigarette use
Is she sexually active? Last menses.
Hx of sexual abuse/ or forced sexual intercourse
What labs would you order?
Pregnancy test, toxicology, acetaminophen levels,
CMP, Urinalysis
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CASE 9
Consultations
Social Work
Psychiatry

The adolescent tells social worker that her

stepfather had been sexually abusing her
during the last 2 years, which progressed to
anal penetration, and finally, vaginal
penetration during the last month. Last
alleged incident occurred 1 week ago.
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WORK UP
What else would you do?
1. VDRL, HIV, Hepatitis profile
2. NAAT for gonorrhea and chlamydia,
vaginal culture
3. Rectal culture for gonorrhea
4. Refer to Biopsychosocial or ObGyn
for colposcopy
5. Prophylactic antibiotics
Ceftriaxone 125 mg IM, Zythromax 1gm po
and Flagyl 2gm
po immediately)
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COLPOSCOPY

Genitallia:
Annular,
estrogenized hymen
with a healed,
complete laceration
at 9 0clock,
lithotomy position

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COLPOSCOPY

Genitallia:
Annular,
estrogenized
hymen with a
healed,
complete
laceration at
9 0clock,
lithotomy
position

Healed,
complete
laceration
at 9 oclock
(lithotomy
position)
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ANAL FINDINGS

Anus: flattened
rugae,
markedly
decreased anal
tone with
visualization of
pectinate line

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ANAL FINDINGS
Anus

Healed
perianal
laceration at 6
0clock
(supine
position)

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WORK UP

Refer to Unidad Investigacin

Especializada (hotline maltrato: 787749-1333)
Forensic interview (specialized center)
Psychiatric follow up/hospitalization
If last alleged incident had occurred in
last 72 hours,
Collection of forensic evidence (rape kit)
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ROLE OF PHYSICIAN
Conduct a complete medical evaluation
(history, physical exam, order pertinent
labs and studies)
Document official results of labs and
studies in the medical chart
Consult other specialists and
subspecialists as indicated
Interpret findings and diagnosis to
parents/legal guardian
Refer to Family Department, police
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ROLE OF PHYSICIAN
Assume emergency custody of child
(hospitalization) if necessary to protect
the child (Law 246 of 2011)
Testify in court
Be a child advocate
Provide anticipatory guidance and
orientation about child abuse prevention
to parents (Shaken Baby Syndrome, etc)
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CASE 10
4 months old infant referred to PICU from another institution
for work up. The patient born to a 24 y/o G1P0 after a normal
pregnancy and vaginal delivery. BW= 7#, infant discharged
at 48 hours with mother. Infant was doing well until two
weeks ago, when she started having several episodes of ALTE
at home. She was hospitalized in another institution, where
she suddenly suffered an episode of severe bradycardia. The
mother refers she was doing well, when she suddenly
stopped breathing and became flaccid and unresponsive. No
tonic/clonic movements observed. She started CPR and
called the nurses. When they arrived, they found she had
severe bradycardia (HR=48/min). The baby responded to
epinephrine. She was referred for cardiovascular evaluation.
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HOSPITAL COURSE
Pt was admitted to PICU for continuous cardiac
monitoring and observation.
A cardiology consult was
requested.
The infant had no further episodes of bradycardia in the
PICU. Pt was transferred to the Pediatric Ward. The patient
remained well during the first 24 hours. The mother was
informed that patient would be discharged the following day,
since all work up was normal.
The next morning, at 7 AM, the mother started shouting,
that the infant had another episode and she had to give her CPR
again. She continued screaming, that she couldnt take her
baby home; something was wrong with her. The baby was found
gasping, flaccid, unresponsive but responded well to Ambu; no
epinephrine was necessary.
The social worker interviewed her and she admitted to
having problems with husband, and that he had left the home a
month ago.
She had many health problems, too but they
couldnt find out what was wrong with her. Her symptoms had
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improved since the baby started
having these episodes.

DIFFERENTIAL DIAGNOSIS
What is your differential diagnosis?
1.Congenital Heart Disease
2.Cardiac Arrhthmia
3.Seizure Disorder
4.Gastroesophageal Reflux
5.Medical Child Abuse/ Munchausen
Syndrome by Proxy
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STUDIES
What studies would you order?
1.EKG
Normal
2.Echocardiogram
Normal
3.Holter
Normal
4.EEG
Normal
5.Barium swallow
Normal
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WHAT IS YOUR DIAGNOSIS?

Medical Child Abuse/ Munchausen

Syndrome by Proxy

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CASE 11
This 2 months old baby is admitted due to
irritability. The infant was born to a 23 y/o G1
P1 A0 after a pregnancy complicated by
premature labor, which required hospitalization
for 1 week. Baby born by SVD at 31 weeks
gestation. BW= 1.8 kilos. Remained in NICU for
1 month, diagnosed NEC, Sepsis and was on
parenteral nutrition for 18 days. At home, baby
was on breast feeding only. Was not receiving
any medications or vitamins.
PE normal except widening of left wrist.
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HOSPITAL COURSE
A full work up for sepsis was performed and
patient was started on antibiotics. Blood, urine
and CSF cultures were all negative, Chest X ray
revealed multiple, anterior, healing, rib fractures.
Skeletal survey revealed osteopenia, and fraying
and cupping of distal radius, but no other
fractures.
What labs and studies would you order?
1.Ca= 8.5, P= 2.8, Alk Phosph.= 500
2.Metabolic screening- normal
3.Vit D (25 OH Vit D)= 15 ng/ml (low)
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4.PTH= high

XRAYS AND PHYSICAL FINDINGS

Healing fractures of
anterior ribs

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Widening of Left wrist

WHAT IS YOUR DIAGNOSIS?

Rickets
Assoc. to prematurity, NEC, TPN,
unsupplemented human milk

Treatment
Vit D 1000 -5000 International
units p.o. daily for 2-3 months;
then 400 International Units/day
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REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.

Reece RM and Christian C. Child Abuse, Medical Diagnosis and

Management. 3rd Edition. China: American Academy of
Pediatrics,2009.
Adams J. Medical Evaluation of Suspected Child Sexual Abuse: 2011
Update. J Child Sexual Abuse.2011; 20(5):588-605.
Christian C, Block R. Abusive Head Trauma in Infants and Children.
Pediatrics 2009; 123(5): 1409-1411
Heger A, Ticson L, Velaszuez O, Bernier R. Children referred for
possible sexual abuse: medical findings in 2384 children. Child Abuse
& Neglect.2002; 26:645-659.
Kellogg N. The Evaluation of Sexual Abuse in Children. Pediatrics
2005; 116 (2): 506-512.
Roesler TA & Jenny C. Medical Child Abuse. USA: American Academy
of Pediatrics, 2009.
Vachharajani, A J, Mathur A M, Rao. R. Metabolic Bone Disease of
Prematurity. NeoReviews 2009;10;e402-e411.
Misra M, Pacaud D, Petryk A, Ferrez Collett-Solberg P, Kappy M.
Vitamin D Deficiency in Children and Its Management: Review of
Current Knowledge and Recommendations. Pediatrics 2008;
122(2):398-417.
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