Classical Findings of Infantile Hepatic Hemangiomas

Hemangiomas are benign vascular tumors that are common during infancy. They are most commonly noted as superficial bright red lesions on the skin but can also be found deeper as subcutaneous lesions. Patients with multifocal cutaneous hemangiomas are at risk of visceral involvement with the liver being most commonly affected. Most hemangiomas can be monitored clinically as they are self-limiting. Despite this, hepatic hemangiomas can have serious complications including large arteriovenous shunts leading to cardiac compromise as well as severe hepatomegaly which can cause abdominal compartment syndrome, impaired ventilation and renal vein compression.

A six-month-old female, born full term and previously healthy, presented due to worsening abdominal distention and hepatomegaly. On examination, abdominal distention, hepatomegaly and three superficial hemangiomas on her torso and scalp were appreciated.

The patient had an extensive workup which showed an elevated AFP and TSH. An abdominal ultrasound revealed numerous rounded regions of hypoechogenicity throughout the hepatic parenchyma. These findings were consistent with diffuse infantile hemangiomas; however, metastasis could not be ruled out with ultrasound alone. An MRI of the abdomen was obtained which confirmed infantile hemangiomas. The patient's MRI and lab findings are the classical findings of infantile hepatic hemangiomas. She had elevated blood pressures during the hospital course and was subsequently evaluated by cardiology for concern of cardiac compromise. Treatment with propranolol was initiated and continued upon discharge. A six month follow-up ultrasound showed significant decrease in size of the hemangiomas.

Hepatic hemangiomas should be monitored closely for serious complications. Although rare, it is important to identify which patients with multifocal cutaneous hemangiomas should be worked up for hepatic hemangiomas and their complications. It is recommended that infants younger than 6 months of age with 5 or more cutaneous hemangiomas undergo early evaluation with abdominal ultrasound.