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It’s a busy Sunday afternoon in the ED. The weather outside is gorgeous (or so you’re told—why don’t they put windows in Emergency Departments?). Anyway, you might have guessed it by the number of lacerations, fractures and general playground mishaps you’ve been seeing. So when the nurse walks by escorting a young man with a bandage on his jaw to the room down the hall, you logically assume it’s another laceration to repair and send the resident in to size things up.

Ok, you’re wrong. The resident comes to find you a short time later with that “help me figure this out” look they get from time to time. She tells you that she doesn’t know what this is but it won’t stop bleeding.
 
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The patient is an eight-year-old male. He has a history of mild asthma but is otherwise healthy. About one month ago his mother noticed a red bump on his left jaw line. It has been increasing in size since then. It does not itch or pain him, in fact they had adopted a ‘wait and see’ approach since he had his annual physical coming up anyway. However, three days ago it started bleeding. Mom’s not sure what he did that started the bleeding, the patient thinks he might have scratched it. They put a Band-Aid on it which seemed to slow things down, but every time they removed the bandaid it was bloody, and today they have switched to gauze, which they are changing every hour or so because it keeps oozing.
 
The child has not had any fevers or systemic symptoms. He hasn’t had any other problems with bleeding or bruising. The family history is negative for anything but asthma and seasonal allergies. The child is taking no medications. His physical exam is completely unremarkable until you remove the bandage.

“What is that?” asks the resident. Underneath the gauze you find a red, soft, bumpy, growth on a small stalk. It is continuously oozing a small trickle of blood, which does not stop with pressure.
What is it? It’s a pyogenic granuloma. These are little capillary hemangiomas that can occur at the site of an injury. They are known to develop in the cysts of acne patients. Hormones can also stimulate their development—they can occur in the gingiva of pregnant patients where they are called epulis.

Pyogenic granulomas are typically less than 1 cm in size. They can be yellow to red in color and dome-shaped. They grow rapidly. Patients most likely to have these are children and young adults. They are most often seen in the head and neck region, as with this patient, or the extremities, particularly the fingers.

The problem with pyogenic granulomas is that they are fragile and bleed easily. The bleeding can be hard to stop, as with this patient. Treatment is curettage, sometimes with electrodessication. It is important to remove all the tissue—if anything is left it tends to recur. Left alone, they will usually resolve spontaneously in about 6 months.

Leaving this alone for 5 more months is not an option in this child—he’s already been bleeding for 3 days. Send him to school like this and the school nurse will be phoning the mother to come get him within the hour. Something needs to be done today.

You control the bleeding temporarily with epinephrine-soaked gauze. You then apply a silver nitrate stick for now. With the bleeding temporarily controlled you refer him to the Surgery clinic for definitive removal of the lesion.

He should do well. The mother will have to monitor him for recurrence. It’s probably a good idea for the surgeons to send the lesion for path after they remove it, just to prove it’s not a melanoma since it grew so fast, but the appearance and course are typical.
 
Amy Levine, MD is an assistant professor of pediatric EM at UNC Chapel Hill.
 

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