Distributive Shock in a Neonate with Diffuse Infantile Hepatic Hemangioma

Hemangiomas are common cutaneous findings on healthy infants. These vascular malformations are generally benign, though in rare circumstances they can potentially be fatal. This is particularly true when the hemangiomas are large or numerous and occurring in visceral organs. Previously unrecognized visceral hemangiomas are part of the differential for any neonate presenting unexpectedly in shock.

A 10-day-old neonate presented to the pediatric emergency department with difficulty breathing. On examination, he appeared to be in respiratory distress and in shock. Echocardiography showed cardiomegaly, and an abdominal ultrasound showed a massive and heterogeneous liver. Magnetic resonance imagine performed after stabilization in the pediatric intensive care unit verified the presence of diffuse infantile hepatic hemangiomas. This case demonstrates how numerous visceral hemangiomas can generate high-volume vascular steal, distributive shock, and cardiac failure. Our patient was subsequently noted to have bruits over his liver. WHY AN EMERGENCY PHYSICIAN SHOULD BE AWARE OF THIS?: Diffuse hemangiomas and arteriovenous malformations are rare causes of extrinsic cardiogenic shock in the neonate. Targeted palpation of an enlarged liver or auscultation of a right upper quadrant bruit can raise suspicion of this diagnosis.