Unilateral retinal hemorrhages with subarachnoid hemorrhage in a 5-week-old infant: is this nonaccidental injury?
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Published on: June 18, 2021
Aravind R Reddy1, Michael Clarke, Vernon W Long
1Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK. ar@rcsed.ac.uk
Insights
Arteriovenous malformation can cause infant retinal hemorrhages, mimicking abusive head injury. Early diagnosis is crucial to avoid misdiagnosis of nonaccidental injury (NAI) and its severe consequences.
Area of Science:
- Pediatric Ophthalmology
- Neuroradiology
- Forensic Medicine
Background:
- Retinal hemorrhages in infants are a critical sign for diagnosing nonaccidental injury (NAI), also known as abusive head injury.
- NAI diagnosis carries significant social and legal ramifications.
- Differential diagnoses for infant retinal hemorrhages include birth trauma, accidental head injury, and medical conditions like leukemia or clotting disorders.
Observation:
- A 5-week-old infant presented with drowsiness, hypotonia, unilateral retinal hemorrhages, and posterior fossa intracranial hemorrhage.
- Nonaccidental injury (NAI) was a primary concern, causing parental distress.
- The etiology of the intracranial hemorrhage was not immediately apparent, requiring further investigation.
Findings:
- Repeat neuroimaging weeks later revealed an arteriovenous malformation as the cause of the intracranial hemorrhage.
- Arteriovenous malformation is identified as a potential, though not always easily diagnosed, cause of retinal hemorrhages in infants.
Implications:
- This case highlights the importance of considering arteriovenous malformations in the differential diagnosis of infant retinal hemorrhages.
- Accurate diagnosis is vital to prevent the misattribution of NAI, which has severe legal and social consequences.
- Timely identification of the underlying cause, such as arteriovenous malformation, is essential for appropriate management and to avoid wrongful accusations.
Purpose:
Retinal hemorrhages are an important sign in the setting of nonaccidental injury (NAI) (abusive head injury) in young infants and form a very important part of the evidence in support of the diagnosis. The diagnosis of NAI has serious social and legal implications. Other causes of retinal hemorrhages in an infant, such as birth trauma, accidental head injury, subarachnoid hemorrhage, other less common disorders of clotting, leukemia, and infections such as endocarditis, need to be considered and ruled out in making a diagnosis of NAI.
Methods:
Descriptive case report.
Results:
A 5-week-old child presented with rapid onset of symptoms of drowsiness and hypotonia, unilateral retinal hemorrhages, and an intracranial hemorrhage in the posterior fossa. NAI was high on the list of differential diagnosis, which caused considerable anxiety in the parents. The cause of the intracranial hemorrhage only became apparent at repeat neuroimaging several weeks later.
Conclusions:
The case is presented to point out arteriovenous malformation as a possible cause of retinal hemorrhages in this age group where an early diagnosis of the etiology is often not possible. A diagnosis of NAI, commonly associated with a similar clinical presentation, can have serious social and legal implications.
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