TGF- Blood. 1997;89:1491–1500

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Foundation, the Reconstructive Plastic Surgery Research Founda-tion, the Maurice and Phyllis Paykel Trust, Lottery Health Re-search, and the Health Research Council of New Zealand.

We are grateful to C. Marstella for her assistance in the prep-aration of this manuscript.

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1. Mulliken JB, Young AE.Vascular Birthmarks: Hemangiomas and Vascular Malformations.Philadelphia, PA: WB Saunders; 1988:41–103

2. Hidano A, Nakajima S. Earliest features of the strawberry mark in the newborn.Br J Dermatol.1972;87:138 –144

3. Amir J, Metzker R, Krikler R, Reisner SH. Strawberry haemangioma in preterm infants.Pediatr Dermatol.1986;3:131–132

4. Margileth AM, Museles M. Cutaneous hemangiomas in children: diag-nosis and conservative management.JAMA.1965;194:523–552 5. Cheung DSM, Warman ML, Mulliken JB. Haemangioma in twins.Ann

Plast Surg.1997;38:269 –274

6. Takahashi K, Mulliken JB, Kozakewich HPW, Rogers RA, Folkman J, Ezekowitz RAB. Cellular markers that distinguish the phases of hem-angioma during infancy and childhood.J Clin Invest.1994;93:2357–2364 7. Folkman J, Klagsbrun A. Angiogenesis factors. Science. 1987;235:

442– 447

8. Folkman J. Angiogenesis in cancer, vascular, rheumatoid, and other diseases.Nature Med.1995;1:27–31

9. Fishman SJ, Mulliken JB, MacDonald DM, Folkman J. Urinarybasic fibroblastic growth factor is useful in differentiating hemangiomas from vascular malformations. Proceedings of the 11th International Work-shop on Vascular Anomalies; Rome, Italy; June 23–26, 1996; page 14 10. Mulliken JB, Boon LM, Takahashi K, Ohlms LA, Folkman J, Ezekowitz

AB. Pharmacologic therapy for endangering hemangiomas.Curr Opin Dermatol.1995;109 –113

11. Zide BM, Glat PM, Stile FL, Longaker MT. Vascular lip enlargement: part I. Hemangiomas—tenets of therapy.Plast Reconstr Surg.1997;100: 1664 –1673

12. Landthaler M, Hohenleutner U, Abd El-Raheem T. Laser therapy of childhood haemangiomas.Br J Dermatol.1995;133:275–281

13. Cremer H. The importance of contact cryosurgery in early therapy of hemangiomas in infancy. Proceedings of the 11th International Work-shop on Vascular Anomalies; Rome, Italy; June 23–26, 1996; page 6 14. Breuninger LM, Dempsey WL, Uhl J, Murasco DM. Hydrocortisone

regulation of IL-6 protein production by purified population of human peripheral blood monocytes. Clin Immunol Immunopathol. 1993;69: 205–214

15. Almawi WY, Beyhum HN, Rahme AA, Rieder MJ. Regulation of cyto-kine and cytocyto-kine receptor expression by glucocorticoids.J Leukoc Biol. 1996;60:563–572

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17. Cai J, Zheng T, Lotz M, Zhang Y, Masood R, Gill P. Glucocorticoids induce Kaposi’s sarcoma cell proliferation through the regulation of TGF-b.Blood.1997;89:1491–1500

18. Barnes PJ. Anti-inflammatory mechanisms of glucocorticoids. Trans Biochem Soc.1995;23:940 –945

19. Ru¨ger BM, Dunbar PR, Hasan Q, Sawada H, Kittleberger R, Greenhill N, Neale TJ. Human mast cells produce type VIII collagen in vivo.Int J Exp Pathol.1994;75:397– 404

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22. Jurecic R, Nguyen T, Belmont JW. Differential mRNA display using anchored oligo-dT and long sequence-specific primers as arbitrary primers.Trends Genet.1996;12:502–504

23. Kushner BJ. The treatment of periorbital infantile hemangioma with intralesional corticosteroid.Plast Reconstr Surg.1985;76:517–524 24. Wyman LC, Fulton GP, Shulman MH. Direct observations on the

cir-culation in the hamster cheek pouch in adrenal insufficiency and ex-perimental hypercorticalism.Ann N Y Acad Sci.1953;56:643– 658 25. Border WA, Rouslahti E. Transforming growth factor-bin disease: the

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Gastric Perforation Attributable to

Liquid Nitrogen Ingestion

ABSTRACT. Despite the widespread use of liquid nitro-gen in medicine and industry, there are only a few reports of injuries associated with its use. We report a case of a 13-year-old boy who developed gastric perforation after liquid nitrogen ingestion. This is a previously unreported complication. Pediatrics 2000;105:121–123; liquid nitrogen, perforation, stomach, inhalation, ingestion.

ABBREVIATION. GI, gastrointestinal.

I

njuries related to liquid nitrogen exposure are

usually either attributable to direct contact (face,

limbs) or a result of inhalation of the evaporated

liquid (damage to the mucosa of the upper

respira-tory or gastrointestinal [GI] tract). Ingestion of liquid

nitrogen is extremely uncommon and gastric

perfo-ration has not previously been reported. This article

reports such a case.

CASE PRESENTATION

A 13-year-old boy was transferred to our hospital after ingest-ing of a mixture of orange crystals with liquid nitrogen. This was a part of a science experiment in which students were given orange crystals, liquid nitrogen, and water to mix and produce a frozen drink to demonstrate the freezing effect of liquid nitrogen. After swallowing the still smoking mixture, he instantly devel-oped an intense burning sensation in the back of his throat and severe abdominal pain, followed by abdominal distention and shortness of breath. On examination in the referring hospital he was hemodynamically stable. Bilateral cervical subcutaneous em-physema was noted. There were no burns to his face, lips, or tongue. There was decreased air entrance to both lungs. The

Received for publication Jan 1, 1999; accepted May 5, 1999.

Reprint requests to (B.Z.K.) Department of Radiology, Hadassah Medical Center, PO Box 12000, Jerusalem 91120, Israel. E-mail: bkoplewitz@ hadassah.org.il

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abdomen was distended and rigid. Chest radiograph showed bilateral cervical subcutaneous emphysema and intraperitoneal free air (Fig 1). Intubation was performed for airway protection and the patient was transferred to our hospital. On examination on arrival the abdomen was grossly distended, tympanic, and diffusely tender. Nasogastric tube drained brown liquid that was positive for occult blood. Laboratory examinations showed mild respiratory acidosis (pH 7.28, Pco254 mm Hg, Po263 mm Hg,

HCO3226 mEq/L, base excess:21) but were otherwise normal.

The patient was taken to the operating room for exploration because of a presumed bowel perforation.

At operation, a large gush of air was evacuated by an upper abdominal midline incision. There was no evidence for blood or free fluid in the abdomen. Two small perforation sites were found in the posterior aspect of the stomach along the lesser curvature. The adjacent gastric mucosa appeared healthy and viable. The two perforation sites were united and closed in two layers. Examina-tion of the gastroesophageal juncExamina-tion and the remainder of the abdomen did not reveal any other injury. Follow-up upper GI series was performed on the 7th postoperative day and showed no evidence of esophageal perforation or injury. There was an irreg-ular area delineated by contrast along the lesser curvature, pre-sumably at the site of the sutured perforation (Fig 2). The patient had an uncomplicated recovery course and was discharged 10 days after the operation. The 4-month clinic visit was normal and he was discharged from long-term follow-up.

Because this child ingested the liquid nitrogen in a formal learning setting, the issue of child protection arose and an inves-tigation was conducted by the authorities. It was then determined that this was an experiment that had been conducted at this setting for many years without consequences and that instructions for this experiment were also available on the Internet. No child protec-tion concerns were verified.

DISCUSSION

Nitrogen is normally a colorless and odorless,

nearly inert, slow reacting gas with a boiling point of

2 195°C. It is widely used in scientific and industrial

institutions, mainly for freezing and cooling, and

also serves as a therapeutic agent in various medical

disciplines. Despite its widespread use, there are

only occasional reports of associated injuries.

1–3

Injuries directly related to storage or use of liquid

nitrogen are usually a result of cold burn to the organ

exposed by direct contamination or inhalation.

Inad-vertent spillage may result in severe frostbite,

possi-bly leading to gangrene that may also cause infection

or may necessitate amputation of the affected organ.

1

Inhalation may lead to mucosal injury of the upper

airway, oropharynx, or hypopharynx, with the risk

of delayed perforation at these sites.

2

_Potential

com-plications include infection and healing-associated

strictures. Inspired gas may replace oxygen in the

blood stream and cause neurologic symptoms

attrib-utable to asphyxia, and death.

3

The use of liquid nitrogen for making ice cream is

available on the Internet, based on an article

pub-lished in 1994.

4

_{This article stresses 2 important}

safety points. The first is to avoid contact with liquid

nitrogen or objects exposed to its extreme cold. The

second is to wait until the ice cream has stopped

giving off fog, which is a signal that all of the liquid

nitrogen has evaporated, before eating it.

A combination of 2 mechanisms is probably

re-sponsible for gastric perforation in this patient: focal

perforation caused by the very low temperature of

the swallowed nitrogen, together with rapid

expan-sion within the closed cavity of the stomach on

evap-oration. The patient did not have pathologic changes

elsewhere in the abdomen.

The very low temperature of liquid nitrogen may

cause mucosal ulcers that may lead to later

perfora-tion when involving respiratory or digestive tract

mucosa. Despite accurate history and a detailed

physical examination, no burns were found in the

oropharynx or hypopharynx of this patient to

ex-plain his burning sensation; this may be attributed to

the very low temperature of the swallowed

sub-stance. Because of the lack of chest pain or

pharyn-geal findings, we did not suspect esophapharyn-geal injury,

and the findings of subcutaneous and mediastinal

emphysema are likely a result of air leak from the

peritoneum. The patient did not have any neurologic

signs or symptoms (the presence of which would

Fig 1. Admittance chest radiograph, demonstrating cervical sub-cutaneous emphysema and intraperitoneal free air.

Fig 2. Postoperative upper GI series in the prone position, show-ing irregularity at the sutured perforation site along the lesser curvature (arrow).

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have indicated gas inspiration with hypoxemia

at-tributable to oxygen replacement) and had an

un-eventful recovery.

The only similar case was that of a chemical

engi-neering student who drank a beaker of liquid

nitro-gen and developed immediate pain and collapsed.

He was found to have free air under the diaphragms

and pneumomediastinum but no perforations. Full

recovery followed supportive care (Cynthia Aaron,

personal communication, 1998).

Although liquid nitrogen instantaneously becomes

a gas in room temperature, it appears that the

inges-tion of a liquid nitrogen mixture may cause mucosal

injury and perforation of the intraabdominal GI tract

with immediate or delayed presentation; symptoms

may be unrelated to the true nature of the more

severe pathology. High index of suspicion of a

pos-sible gastric injury (despite lack of facial or

oropha-ryngeal findings) should be maintained and can lead

to a prompt diagnosis and an appropriate

manage-ment. Efforts should be made to educate the general

public and especially science teachers regarding the

potential harmful effects of liquid nitrogen in food

products.

Benjamin Z. Koplewitz, MD, BSc*

Alan Daneman, MB, BCh, Sc, FRACR, FRCPC* Sigmund H. Ein, BA, MDCM, FRCS(C), FACS,

FAAP¶

Michael A. McGuigan, MD, CM, MBA‡ Marcellina Mian, MDCM§

*Departments of Diagnostic Imaging, ‡Clinical Pharmacology/Toxicology, and §SCAN Program ¶Division of General Surgery

Hospital for Sick Children and the University of Toronto

Toronto, Ontario, Canada M5G 1X8

REFERENCES

1. Roblin P, Richards A, Cole R. Liquid nitrogen injury: a case report. Burns.1997;23(7– 8):638 – 640

2. Rockawold G, Buran DJ. Inhalation of liquid nitrogen vapor.Ann Emerg Med.1982;11:553–555

3. Kernbach-Wighton G, Hijewski H, Schwanke P, et al. Clinical and morphological aspects of death due to liquid nitrogen.Int J Legal Med. 1998;111:191–195

4. Kurnti N, This-Benckhard H. Chemistry and physics in the kitchen.Sc Am.1994;270:66 –71

Forehead Lipoblastoma Mimicking

a Hemangioma

ABSTRACT. A case of forehead lipoblastoma simulat-ing a hemangioma in a male infant is reported, to alert pediatricians to this rare tumor and to increase the index of suspicion in atypical hemangiomas.

A 2-month-old male infant developed a protruding forehead mass with increased vascularity. It demon-strated progressive and accelerated growth over the sub-sequent 6 months, unresponsive to steroid therapy. A magnetic resonance imaging scan supported the diagno-sis of hemangioma because of the hypervascular nature of the lesion. Surgical excision was performed because of visual obstruction. Pathologic examination of the speci-men was consistent with a very primitive lipoblastoma. This tumor is a rare, benign lesion of immature fat cells that is found almost exclusively in the pediatric popula-tion. Lipoblastomas are more common in males than females and frequently present as asymptomatic, rapidly enlarging, soft lobular masses on the extremities. Com-plete surgical excision is the definitive treatment. In the vast majority of reported cases, however, the preopera-tive diagnosis was incorrect, underscoring the diagnostic dilemma presented by these rare tumors.Pediatrics2000; 105:123–128;lipoblastoma, hemangioma.

ABBREVIATIONS. MRI, magnetic resonance imaging; CT, com-puted tomography;

A

lthough hemangiomas are by far the most

common benign tumors of infancy, other

tu-mors will infrequently occur and must be

included in the differential diagnosis.

CASE REPORT

A 7-month-old white boy was referred to the Children’s Hos-pital of Philadelphia for evaluation of a rapidly enlarging forehead mass (Fig 1). His history was notable for having been born 6 weeks prematurely, requiring a 10-day stay in the neonatal intensive care unit and apnea monitoring for 5 months. His parents first noticed a flat red spot on the child’s forehead at 2 months of age. Over the next several months, the spot progressively enlarged (Fig 2). The lesion evolved into a tense lobule with a purple hue and promi-nent cutaneous vessels.

Although hemangioma was felt to be the most likely diagnosis, the rather firm nature of the lesion and relative lack of increased warmth normally associated with hypervascular tissue prompted a magnetic resonance imaging (MRI) study. The study was con-sistent with a large hemangioma measuring 3 3 4.53 5.5 cm overlying the right frontal bone without intracranial extension (Fig 3A and B). Initial ophthalmologic examination did not reveal any evidence of amblyopia, but oral steroid therapy was begun (3 mg/kg/d) because of the risk of impending visual obstruction.

The mass continued to enlarge over the subsequent month, unresponsive to steroid therapy. A repeat ophthalmologic evalu-ation revealed a diffuse amblyopia, attributed to the obstruction of the visual field by the expanding lesion, and a daily patching regimen was begun.

At 8 months of age, the mass measured 7 cm in maximum dimension (Fig 4), and the decision was made to proceed with surgical excision because it continued to expand despite maxi-mum medical treatment, it was causing significant visual obstruc-tion and potentially irreversible disuse amblyopia, and surgical resection of the redundant skin would be necessary even with spontaneous regression. His insurance carrier mandated a second opinion regarding the need for surgery, and evaluation by multi-ple physicians at another institution again confirmed the lesion to be a hemangioma requiring surgical excision because of visual obstruction.

Intraoperative dissection revealed numerous enlarged periph-eral veins, a well encapsulated mass, markedly attenuated fron-talis muscle, and a single enlarged feeding artery from the frontal branch of the right superficial temporal artery. Redundant skin was used to achieve complete skin closure. In subsequent fol-low-up he demonstrated uneventful healing with good symmetry (Fig 5).

Pathologic examination documented an ovoid mass measuring 8.5 3 7.0 3 6.0 cm and weighing 236 g. Multiple thin-walled

Received for publication Feb 8, 1999; accepted Jun 8, 1999.

Address correspondence to David W. Low, MD, Division of Plastic Surgery, Children’s Hospital of Philadelphia, 34th and Civic Center Blvd, Philadel-phia, PA 19104. E-mail: [email protected]

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DOI: 10.1542/peds.105.1.121

2000;105;121

Pediatrics

McGuigan and Marcellina Mian

Benjamin Z. Koplewitz, Alan Daneman, Sc, FRACR, Sigmund H. Ein, Michael A.

Gastric Perforation Attributable to Liquid Nitrogen Ingestion

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DOI: 10.1542/peds.105.1.121

2000;105;121

Pediatrics

McGuigan and Marcellina Mian

Benjamin Z. Koplewitz, Alan Daneman, Sc, FRACR, Sigmund H. Ein, Michael A.

Gastric Perforation Attributable to Liquid Nitrogen Ingestion

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