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A 4-month-old full-term Hispanic boy is brought to the physician for routine examination.
His past medical history is notable for "nonstop crying" of unclear etiology for 2 hours
each day around age 2 months. His parents report that the crying is no longer an issue.
On examination, he can hold onto his bottle for a few seconds but then drops it on the
ground. He is able to sit with truncal support and can roll from front to back. Babinski
reflex is present bilaterally. Flat, nonblanching, nontender patches over his sacrum and
buttocks are shown in the image below.

What is the most appropriate next step in management of this patient?

0 A. Brain magnetic resonance imaging

0 B. Complete blood count and coagulation studies
0 C. Laser therapy
0 D. Reassurance
0 E. Sacral ultrasound
0 F. Skeletal survey

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Item: ~'?Mark ~ f> 6t ~ ~ , GJIIA)
a. ld : 37 55 PreVIOUS Next lab Values Notes Calculator Reverse Color Text Zoom

A 4-month-old full-term Hispanic boy is brought to the physician for routine examination.
His past medical history is notable for "nonstop crying" of unclear etiology for 2 hours
each day around age 2 months. His parents report that the crying is no longer an issue.
On examination, he can hold onto his bottle for a few seconds but then drops it on the
ground. He is able to sit with truncal support and can roll from front to back. Babinski
reflex is present bilaterally. Flat, nonblanching, nontender patches over his sacrum and
buttocks are shown in the image below.

What is the most appropriate next step in management of this patient?

0 A. Brain magnetic resonance imaging

0 B. Complete blood count and coagulation studies
0 C. Laser therapy
0 D. Reassurance
0 E. Sacral ultrasound
0 F. Skeletal survey
0 G. Skin biopsy

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Item:
a. ld : 37 55
~'?Mark ~
PreVIOUS
f>
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a
lab Values
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Calculator
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Reverse Color
GJIIA)
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A 4-month-old full-term Hispanic boy is brought to the physician for routine examination.
His past medical history is notable for "nonstop crying" of unclear etiology for 2 hours
each day around age 2 months. His parents report that the crying is no longer an issue.
On examination, he can hold onto his bottle for a few seconds but then drops it on the
ground. He is able to sit with truncal support and can roll from front to back. Babinski
reflex is present bilaterally. Flat, nonblanching, nontender patches over his sacrum and
buttocks are shown in the image below.

What is the most appropriate next step in management of this patient?

A Brain magnetic resonance imaging [2%]

B. Complete blood count and coagulation studies [5%)
C. Laser therapy [0%]
..; I D. Reassurance [85%]
E. Sacral ultrasound [1%)
F. Skeletal survey [7%]
••

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 What is the most appropriate next step in management of this patient?

A. Brain magnetic resonance imaging [2%]

B. Complete blood count and coagulation studies [5%]
C. Laser therapy [0%)
D. Reassurance [85%]
E. Sacral ultrasound [1%]
F. Skeletal survey [7%)
G. Skin biopsy [0%]
. . . '

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Explanation: User ld
This 4-month-old boy has a normal examination. The image shows congenital dermal
melanocytosis ("Mongo.lian spot"): benign, flat, blue-grey patches that are usually
present over the lower back and buttocks but can also be seen in other parts of the
body. Most infants of African, Asian, Hispanic, and Native American ethnicity have
Mongolian spots at birth, and the hyperpigmentation usually fades spontaneously
during the first decade of life.
It is important for physicians to document the presence of Mongolian spots as these can
be mistaken for bruises, which are also flat, nonblanching, and similar in color. Extensive
bruising would raise concern for coagulopathy or child abuse. Colic (prolonged periods
of inconsolable crying) peaks around age 2 months, can be very frustrating for exhausted
parents, and increases the risk of abuse. Skeletal survey is mandatory in suspected
physical abuse to evaluate for patterns of intentional injury. However, bruises are tender,
more varied in color, and fade quickly, making further workup (Choices B and F)
inappropriate for this patient.
(Choice A) Birthmarks such as cafe-au-lait macules, ash-leaf spots, and port-wine
stains are associated with neurofibromatosis, tuberous sclerosis, and Sturge-Weber
syndrome, respectively. Intracranial lesions and epilepsy are features of these
neurocutaneous syndromes. In contrast, Mongolian spots are not associated with
intracranial lesions, making brain magnetic resonance imaging unnecessary.

(Choice C) Laser therapy would be inappropriate for this infant as Mongolian spots are

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 ore•se1it over can seen
body. Most infants of African, Asian, Hispanic, and Native American ethnicity have
Mongolian spots at birth, and the hyperpigmentation usually fades spontaneously
during the first decade of life.

It is important for physicians to document the presence of Mongolian spots as these can
be mistaken for bruises, which are also flat, nonblanching, and similar in color. Extensive
bruising would raise concern for coagulopathy or child abuse. Colic (prolonged periods
of inconsolable crying) peaks around age 2 months, can .be very frustrating for exhausted
parents, and increases the risk of abuse. Skeletal survey is mandatory in suspected
physical abuse to evaluate for patterns of intentional injury. However, bruises are tender,
more varied in color, and fade quickly, making further workup (Choices B and F)
inappropriate for this patient.
(Choice A) Birthmarks such as cafe-au-lait macules, ash-leaf spots, and port-wine
stains are associated with neurofibromatosis, tuberous sclerosis, and Sturge-Weber
syndrome, respectively. Intracranial lesions and epilepsy are features of these
neurocutaneous syndromes. In contrast, Mongolian spots are not associated with
intracranial lesions, making brain magnetic resonance imaging unnecessary.

(Choice C) Laser therapy would be inappropriate for this infant as Mongolian spots are
benign and usually fade spontaneously. In addition, laser therapy has the potential side
effect of post-inflammatory hyperpigmentation.
(Choice E) Cutaneous stigmata of occult spinal cord malformations include·sacral
dimples and hair tufts. Because this infant has a normal neurologic examination
(Babinski reflex is normal at age <1 year) and Mongolian spots are not associated with
spinal dysraphisms, sacral ultrasound is not warranted.
(Choice G) Mongolian spots are not associated with malignant transformation.
Diagnosis is mainly clinical. As a result, skin biopsy is not warranted.
Educational objective:
Mongolian spots are commonly found in African, Asian, Hispanic, and Native American
infants and usually fade spontaneously during childhood.

Reference.s:
1. Hypermelanoses of the newborn and of the infant.
2. A birthmark survey in 500 newborns: clinical observation in two
northern Taiwan medical center nurseries.

Time Spent 14 seconds Copyright© UWorld Last updated: [09/17/201 6)

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J lait macule

- Mongolian spot - - - • 0
1-1- Dermatology
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us Sderosis (Ash Leaf Marks)

- Mongolian spot - - - • 0
1- -1- - Dermatology
--------------------------- -
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Media Exhibit

limple

- Mongolian spot - - - • 0
11 Dermatology Feedback End Block
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