Propranolol was incidentally discovered in 2008 as a treatment for infantile hemangiomas and has now emerged as first-line therapy. Propranolol's mechanism of action of has been hypothesized to include its effects by vasoconstriction and downregulation of growth factors. It can be administered orally at low doses or applied topically, using drops or gels.
The most concerning possible side effects of propranolol include hypotension, bradycardia, hypoglycemia, hyperkalemia, and bronchospasm. For these reasons, many clinicians and institutions choose to initially administer the medication to children during an inpatient visit, especially for younger patients, in whom oral administration is chosen over topical treatment.[7,8]
The infant in this case was admitted to a nearby children's hospital for initiation of oral propranolol to treat the infantile hemangioma. Before beginning the treatment, MRI of the spine was successfully obtained (without sedation). The MRI results identified an enhancing tract connecting the skin with the paraspinal soft tissues at the level of L4/L5; however, no definitive communication with the spinal canal was seen (although subtle communication could not be excluded). Surface thickening of the skin above the tract compatible with given history of an infantile hemangioma was noted. Finally, the conus medullaris terminated at L2-L3 spinal level, with no tethering, which was a normal location for the patient's age. No other abnormalities were reported.
Propranolol was started, with a 3-day regimen: 0.5 mg/kg/day divided three times on the first day, then 1 mg/kg/day divided three times on the second day, then 2 mg/kg/day divided three times on the third day. Continuous monitoring and frequent vitals revealed a normal heart rate and blood pressure throughout. Electrolyte levels, including glucose levels, were also normal throughout.
After tolerating the final goal dose of 2 mg/kg/day divided three times per day, the patient was discharged home with a 1-week follow up to assess the infantile hemangioma in the oncology clinic. A 2-month follow-up with neurosurgery to repeat the MRI of the lumbosacral region was also indicated.
At primary care follow-up 2 weeks later, the parents were pleased with the treatment and the interval improvement of the lesion (Figure 3). A single café au lait spot was also noted on his right upper back during this visit.
The patient was lost to follow-up for a short while; however, the family returned at 6 months for a check-up. His dose of propranolol was increased by the outpatient oncologists. The lesion continues to change in appearance, with no further growth and lightening and fading almost completely in some peripheral areas (Figure 4).
The patient's growth is appropriate, his milestones are on track, and he is otherwise in good health.
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Cite this: Dan Beardmore, Saba Fatima. A Newborn Infant With a Lumbar Lesion and Dermal Defect - Medscape - May 15, 2018.