A parent comes to the emergency department with his 2-year-old son because he reports that he has hit his right eye while playing. Indeed, a hematoma is observed on the right eyelid, apparently of no importance. The fundus examination showed intraretinal hemorrhages not only in the eye referred by the parents but also in the other eye. It is noteworthy that the child appears drowsy and with little tone. Which of the following statements should you consider regarding this clinical picture?
Easy question in principle, but with a bit of a catch. If you have the right intuition when you read it and go straight to what you think, you will probably get it right. The problem is option 4, which can confuse us. Let's see: we have a blow to the right eye area, with a hematoma on the eyelid. So far so normal. The problem is that retinal hemorrhages appear not only in that eye (which in itself is rare, because an external blow to the eye in a child rarely causes bleeding in the retina), but also in the other eye. Therefore, something other than the blow has caused hemorrhages in both retinas. Then we are told that the child seems drowsy and with little tone. Here we already have the two keys; we have to suspect what is not mentioned in the answers, but which is what the child has: the shaken baby syndrome (shaken baby syndrome). Characteristic of this syndrome are bilateral retinal hemorrhages, cerebral edema and subdural hematoma. There may also be fracture of long bones and other problems. Numbness and hypotonia allow us to suspect intracranial complications. The cause of shaken baby syndrome is almost always abuse, so the answer is 1. Options 2 and 3 are easy to rule out: nothing indicates perforating trauma, and it does not explain the hemorrhages in the other eye. And the berlin edema is an edema of the macula and appears as a whitish lesion, which is not described in the statement. The catch is option 4. Purstcher's retinopathy can also appear in the context of the child of the shaken child, and therefore occur in the case of child abuse. Seeing these two partly related questions, we may hesitate. However, if we read answer 4 carefully, it does not tell us that if there is child maltreatment Purstcher can occur. It states that the picture described above (intraretinal hemorrhages, without other findings) is characteristic of Purstcher's angiopathy. It is not. In Purstcher's there are hemorrhages, but also cottony exudates and edema. If there are only hemorrhages, it's not Purstcher's. Here's the messy bit, but it's really well worded. If he had a Purstcher it could also be for child abuse, but he doesn't.
It is a highly suggestive history of child abuse.
It is the normal evolution of a non-perforating intraocular trauma.
The most likely diagnosis is Berlin edema.
It is the characteristic picture of Purstcher's traumatic retinal angiopathy.
The cause of shaken baby syndrome is almost always abuse, so the answer is 1.
Options 2 and 3 are easy to rule out: nothing indicates perforating trauma, and it does not explain the hemorrhages in the other eye.
Options 2 and 3 are easy to rule out: nothing indicates perforating trauma, and it does not explain the hemorrhages in the other eye.
In Purstcher's there are hemorrhages, but also cottony exudates and edema. If there are only hemorrhages, it's not Purstcher's.