Surgical management of subcutaneous fat necrosis of the newborn required due to a lack of improvement: a very rare case

Subcutaneous fat necrosis of the newborn: A systematic review of surgical management and outcomes

BACKGROUND

Subcutaneous fat necrosis of the newborn (SCFN) is a rare form of panniculitis manifesting as erythematous plaques or nodules at sites of brown fat in neonates. Surgical management may be indicated in severe cases; however, there is a paucity of literature compiling presentations and outcomes of these surgical patients.

METHODS

The authors performed a systematic review, in consultation with a licensed librarian, on MEDLINE and Embase for studies including patients with SCFN who were surgically managed.

RESULTS

The search strategy generated 705 results, among which 213 (30.2%) were excluded for lack of discussion on surgical management. Twenty-two studies discussed surgical management of SCFN in 26 patients, but in 6 of these studies the patients were not surgically managed. Ultimately, 16 articles with 16 patients who were surgically managed were included in the study. Average age at diagnosis was 11.8 ± 9.8 days; average age at surgery was 39.5 ± 70.4 days. The most common etiologies were "unknown" (6, 37.5%), therapeutic hypothermia (4, 25.0%), and birth complications (4, 25.0%). Patients harbored nodules on the back (14, 87.5%), upper extremities (7, 43.8%), lower extremities (7, 43.8%), buttocks (5, 31.3%), and head or neck (3, 18.8%). Linear regression models revealed the presence of back lesions and predicted concomitant medical complications (β = 2.71, p = 0.021).

CONCLUSIONS

Patients undergoing surgical management for SCFN most commonly harbor lesions on the back and extremities that are secondary to therapeutic hypothermia or of unknown origin. Reporting of additional cases is needed to further elucidate surgical management and outcomes.

Subcutaneous fat necrosis in newborns: a systematic literature review of case reports and model of pathophysiology

BACKGROUND

Subcutaneous fat necrosis of the newborn (SCFN) is a rare disease occurring in the first days of life. Characteristically, the infants show hard nodules in subcutaneous tissue, purple or erythematous in color and appear on the upper back, cheeks, buttocks and limbs. In most cases, SCFN is a self-limiting disease, as the nodules disappear in up to 6 months. A severe complication associated with SCFN is hypercalcaemia. Pathophysiological mechanisms causing SCFN or associated hypercalcaemia are not fully understood yet.

METHODS

A systematic literature research including the six biggest databases for medical research has been used to identify all published case reports of SCFN. N = 206 publications has been identified containing n = 320 case reports. All cases have been classified into four subgroups (depending on reported serum-calcium-level): hypercalcaemia, normocalcaemia, hypocalcaemia or no information given. Reported maternal factors, birth characteristics, details about SCFN, diagnostics, therapy and long-term observations have been extracted from publications.

RESULTS

This is the first systematic literature research that summed up all published cases of SCFN from 1948 up to 2018. Information about serum calcium level was given in 64.3% of the cases. From those, the majority showed hypercalcaemia (70.5%) (normocalcaemia 25.1%, hypocalcemia 4.3%). 89.3% of newborns with hypercalcaemia showed suppressed levels of the parathormone. Maternal gestational diabetes, maternal hypertensive diseases during pregnancy, macrosomia (> 4000g), asphyxia and therapeutic hypothermia are risk factors for SCFN. Histological findings showed a granulomatous inflammation in 98% of cases.

CONCLUSION

We identified that maternal, birth characteristics and therapeutic measures are probably risk factors for SCFN. These risk factors should be taken into account within the care of neonates.

Report of 2 Novel Presentations of Subcutaneous Fat Necrosis of the Newborn

Subcutaneous fat necrosis of the newborn (SCFNN) is a rare form of panniculitis classically affecting healthy full-term infants. There are a number of predisposing factors including perinatal asphyxia. The condition generally has a benign course with spontaneous resolution, but monitoring for metabolic complications, in particular the potentially life-threatening complication of hypercalcaemia, is critical. The authors report 2 cases of preterm infants with perinatal asphyxia with atypical presentations of SCFNN: the first with bony involvement resembling Langerhans cell histiocytosis and with follicular pseudocarcinomatous hyperplasia on histology; and the second presenting with a huge haematoma requiring surgical debridement. Both cases were initially erroneously diagnosed as pyogenic infections.

Calcium management challenges in a macrosomic child with subcutaneous fat necrosis

We present a case that illustrates the fluctuations in calcium levels to be expected while managing an infant with maternal gestational diabetes mellitus who also develops subcutaneous fat necrosis (SCFN). There is initial hypocalcaemia due to functional hypoparathyroidism, requiring judicious calcium replacement. But with increased extrarenal production of 1,25-dihydroxyvitamin D due to granulomatous inflammation of subcutaneous adipose tissue, hypercalcaemia ensues. With a self-limiting course, SCFN of the newborn has an excellent prognosis and resolves spontaneously. However, aberrations in serum calcium levels can manifest in life-threatening complications and must hence be closely monitored.

Subcutaneous fat necrosis requiring plastic surgical intervention in an infant treated with whole-body cooling

We report an infant who developed subcutaneous fat necrosis of the newborn (SCFN) secondary to cooling treatment for hypoxic ischaemic encephalopathy (HIE). While SCFN is usually self-limiting, this patient went on to develop a large haematoma on his back with overlying skin necrosis necessitating debridement and split thickness skin grafting. Initially, the area affected on his back showed a number of small fluctuant swellings. By day 16 after birth, theses swellings coalesced to form a large 15 cm × 19 cm haematoma with a tense, shiny skin overlying it. On day 17, the large swelling was drained in theatre and a drain was left in situ. Total calcium blood level was raised at 4 mmol/l and he was managed with Pamidronate infusion. Postoperatively, examination of the back showed a 5 cm necrotic area in the centre of the back, and affected area was debrided along with a split skin graft applied to the exposed area.