Subcutaneous Fat Necrosis and Hypercalcemia After Therapeutic Hypothermia in Patients With Hypoxic-ischemic Encephalopathy: A Case Series

Subcutaneous fat necrosis of the newborn with follow-up of the hypercalcemia A thirteen-day-old boy is diagnosed with subcutaneous fat necrosis of the newborn after the appearance of erythematous, subcutaneous plaques on the right shoulder. This rare, usually self-limiting cutaneous disease is mainly diagnosed in term and postterm infants. The diagnosis is confirmed by a skin biopsy. Various etiological hypotheses are suggested, although the exact pathogenesis needs to be elucidated. The disease might be associated with several maternal and foetal predisposing factors, including therapeutic hypothermia at birth as part of hypoxic ischemic encephalopathy. It is a benign inflammation of the subcutaneous adipocytes that can be accompanied by life-threatening complications, such as hypercalcemia and thrombocytopenia. The latter requires rigorous follow-up and, in some cases, also treatment. The skin damage should only be treated symptomatically with analgesia.

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Extensive subcutaneous fat necrosis after selective head cooling in a newborn with hypoxic ischemic encephalopathy

Dermatologica Sinica ◽

10.1016/j.dsi.2016.01.005 ◽

2016 ◽

Vol 34 (4) ◽

pp. 211-212

Author(s):

Kai-Lung Chen ◽

Chien-Yi Chen ◽

Hsien-Ching Chiu

Keyword(s):

Subcutaneous Fat ◽

Hypoxic Ischemic Encephalopathy ◽

Fat Necrosis ◽

Subcutaneous Fat Necrosis ◽

Head Cooling ◽

Ischemic Encephalopathy

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Subcutaneous fat necrosis, a rare but serious side effect of hypoxic-ischemic encephalopathy and whole-body hypothermia

Journal of Perinatal Medicine ◽

10.1515/jpm-2019-0172 ◽

2019 ◽

Vol 47 (9) ◽

pp. 986-990 ◽

Cited By ~ 1

Author(s):

Mahdi Alsaleem ◽

Lina Saadeh ◽

Valerie Elberson ◽

Vasantha H.S. Kumar

Keyword(s):

Therapeutic Hypothermia ◽

Subcutaneous Fat ◽

Whole Body ◽

Subcutaneous Fat Necrosis ◽

P Values ◽

Life Threatening ◽

The Mean ◽

Body Cooling ◽

Whole Body Cooling ◽

Ischemic Encephalopathy

Abstract Objective To describe the clinical characteristics and risk factors in infants with subcutaneous fat necrosis (SFN) following therapeutic hypothermia for hypoxic-ischemic encephalopathy (HIE). Methods A case-control study was performed by a retrospective chart review of infants with moderate or severe HIE admitted to a level IV regional perinatal center and who underwent whole-body cooling. Results A total of 14 (8.1%) of 171 infants with moderate or severe HIE who underwent whole-body cooling developed SFN during hospitalization. There were more females [71% (10/14)] and large-for-gestational age (LGA) infants [28% (4/14)] in the SFN group vs. 36% females (57/157) and 8% LGA infants (13/157) in the group without SFN (P-values of 0.009 and 0.015, respectively). The mean lowest platelet count was lower 108 ± 55 109/L vs. 146 ± 62 109/L and the mean highest calcium level was higher 11.3 ± 2.5 vs. 10.6 ± 0.8 mg/dL in infants with SFN vs. infants without SFN, respectively (P-values of 0.0078 and 0.006, respectively). Distribution of skin lesions followed distinctive patterns representing the areas with direct contact with the cooling blanket. One infant developed severe, life-threatening hypercalcemia that required aggressive management, including diuretics, corticosteroids and bisphosphonates. Conclusion Although SFN is a rare complication of therapeutic hypothermia, it can be a life-threatening condition if complicated by severe hypercalcemia. Infants who undergo therapeutic hypothermia for HIE need regular skin examinations to evaluate for SFN. If SFN is identified, monitoring of serum calcium levels to prevent life-threatening hypercalcemia is recommended.

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Subcutaneous Fat Necrosis After Moderate Therapeutic Hypothermia in Neonates

PEDIATRICS ◽

10.1542/peds.2010-3508 ◽

2011 ◽

Vol 128 (2) ◽

pp. e450-e452 ◽

Cited By ~ 47

Author(s):

B. Strohm ◽

A. Hobson ◽

P. Brocklehurst ◽

A. D. Edwards ◽

D. Azzopardi ◽

...

Keyword(s):

Therapeutic Hypothermia ◽

Subcutaneous Fat ◽

Fat Necrosis ◽

Subcutaneous Fat Necrosis

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Pamidronate as first-line treatment of hypercalcemia in neonatal subcutaneous fat necrosis: A case series

Paediatrics & Child Health ◽

10.1093/pch/pxz141 ◽

2019 ◽

Author(s):

Alexander D Chesover ◽

Jennifer Harrington ◽

Farid H Mahmud

Keyword(s):

Serum Calcium ◽

Subcutaneous Fat ◽

Case Series ◽

Retrospective Chart Review ◽

Bisphosphonate Therapy ◽

Fat Necrosis ◽

First Line ◽

Retrospective Case ◽

Subcutaneous Fat Necrosis ◽

Severe Hypercalcemia

Abstract Background Subcutaneous fat necrosis (SCFN) can be complicated by severe hypercalcemia, which is frequently asymptomatic. Nephrocalcinosis is associated with hypercalcemia and, in other clinical settings, has been linked to furosemide and glucocorticoid use. First-line bisphosphonate therapy treating hypercalcemia in neonatal SCFN is not well described. Objectives To describe the biochemical changes and risk of nephrocalcinosis in infants with hypercalcemia, secondary to neonatal SCFN, treated with initial pamidronate. Methods A retrospective chart review of five infants treated with initial pamidronate and without furosemide or glucocorticoids. Data were collected on the following: timing of presentation, therapeutic response, and presence of nephrocalcinosis. Results Hypercalcemia resolved after 2.8±1.7 days; this is compared to 7.6±2.8 days from previously reported cases utilising alternative therapies (P=0.012). There were no episodes of rebound hypercalcemia or hypocalcemia. Nephrocalcinosis was present in four of five cases. When including published cases, age at diagnosis was associated with presenting serum calcium (P=0.003) and nephrocalcinosis was associated with higher serum calcium (P=0.014) and time from SCFN to hypercalcemia diagnosis (P=0.002). Conclusions This retrospective case series demonstrates that first-line pamidronate treatment was effective and safe in the resolution of hypercalcemia. Nephrocalcinosis was observed, despite the avoidance of furosemide and glucocorticoid therapy, and associated with greater disease severity and duration of hypercalcemia.

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Subcutaneous Fat Necrosis in a Newborn after Brief Therapeutic Hypothermia: Ultrasonographic Examination

Pediatric Dermatology ◽

10.1111/pde.12454 ◽

2014 ◽

Vol 32 (3) ◽

pp. 427-429 ◽

Cited By ~ 2

Author(s):

Linda Tognetti ◽

Georgios Filippou ◽

Sara Bertrando ◽

Valentina Picerno ◽

Giuseppe Buonocore ◽

...

Keyword(s):

Therapeutic Hypothermia ◽

Subcutaneous Fat ◽

Fat Necrosis ◽

Subcutaneous Fat Necrosis ◽

Ultrasonographic Examination

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Haematoma complicating subcutaneous fat necrosis of the newborn: a rare complication following therapeutic hypothermia

BMJ Case Reports ◽

10.1136/bcr-2020-234360 ◽

2020 ◽

Vol 13 (6) ◽

pp. e234360

Author(s):

Elhaytham Omar Sanad Elsayed ◽

Kamran Yusuf ◽

Frankie O G Fraulin ◽

Prashanth Murthy

Keyword(s):

Therapeutic Hypothermia ◽

Neonatal Intensive Care ◽

Rare Complication ◽

Subcutaneous Fat ◽

Meconium Aspiration Syndrome ◽

Large For Gestational Age ◽

Unusual Complication ◽

Skin Defect ◽

Fat Necrosis ◽

Subcutaneous Fat Necrosis

A term, large for gestational age male newborn, was admitted to the neonatal intensive care unit with meconium aspiration syndrome and severe hypoxic-ischaemic encephalopathy. The baby was treated with therapeutic hypothermia using a total body cooling blanket. After 48 hours, the baby developed tender, indurated subcutaneous nodules consistent with subcutaneous fat necrosis (SCFN). The lesions started initially over the back but gradually spread to cover both shoulders, upper arms, chest area and both thighs. On day 19 of life, multiple small nodules on the back softened and coalesced to form one sizeable fluctuant swelling over the thoracolumbar area. Over a few hours, the swelling rapidly progressed to a large, tense mass with sloughing of the gangrenous overlying skin. This unusual complication of SCFN required surgical intervention for evacuation and debridement of the haematoma followed by graft repair of the skin defect.

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Is Therapeutic Hypothermia Real Cause of Subcutaneous Fat Necrosis in Newborns?

The Indian Journal of Pediatrics ◽

10.1007/s12098-012-0746-4 ◽

2012 ◽

Vol 80 (4) ◽

pp. 355-356

Author(s):

Nilay Hakan ◽

Mustafa Aydin ◽

Ayşegül Zenciroğlu ◽

Sara Erol ◽

Nurullah Okumuş

Keyword(s):

Therapeutic Hypothermia ◽

Subcutaneous Fat ◽

Fat Necrosis ◽

Subcutaneous Fat Necrosis

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Occult Massive Visceral Fat Necrosis Following Therapeutic Hypothermia for Neonatal Encephalopathy

Pediatric and Developmental Pathology ◽

10.1177/1093526617737881 ◽

2017 ◽

Vol 21 (5) ◽

pp. 502-506

Author(s):

Salwa Khedr ◽

Anna Piskorski ◽

Adrienne R Bingham ◽

Justin Goldstein ◽

Abbot R Laptook ◽

...

Keyword(s):

Therapeutic Hypothermia ◽

Visceral Fat ◽

Subcutaneous Fat ◽

Neurodevelopmental Outcome ◽

Pulmonary Artery Hypertension ◽

Whole Body ◽

Common Side Effect ◽

Close Monitoring ◽

Fat Necrosis ◽

Subcutaneous Fat Necrosis

Therapeutic hypothermia (head or whole-body cooling) improves survival and neurodevelopmental outcome in term newborns with moderate-to-severe encephalopathy. Hypothermia treatment is well tolerated; the most common side effect is thrombocytopenia. In about 1% of infants, focal subcutaneous fat necrosis has been reported. We describe a case of clinically unsuspected massive visceral fat necrosis in a term infant with Apgar score 0 at 1 min (“resuscitated apparently stillborn” infant) who was treated with therapeutic hypothermia for 72 h and expired on the 25th day of life following a neonatal course complicated by severe encephalopathy, pulmonary artery hypertension, persistent thrombocytopenia, hypoglycemia, and severe basal ganglia-thalamic abnormalities on magnetic resonance imaging. Postmortem examination revealed extensive visceral (brown) fat necrosis, involving thoracic, abdominal, and retroperitoneal adipose tissue, with distinctive sparing of the subcutaneous (white) fat. The fulminant—yet clinically occult—visceral fat necrosis seen in this case suggests that (lesser degrees of) fat necrosis may go unrecognized in hypoxic-ischemic newborns, especially in those treated with hypothermia, and underscores the importance of close monitoring of encephalopathic newborns both in the short and long terms for complications of fat necrosis (hypercalcemia and nephrocalcinosis).

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