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NBME 24 Answers

nbme24/Block 4/Question#7 (38.2 difficulty score)
A 3-year-old girl is brought to the physician ...
Spontaneous regression🔍
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 +8  upvote downvote
submitted by sangeles(8),

To me it sounds more like nevus simplex. The most common capillary malformation is nevus simplex, which affects more than half of infants. Nevus simplex, or “salmon patch,” lesions are pink, ill-defined patches that tend to occur in midline locations, most frequently on the nape of the neck, glabella, eyelids, nose/lips, scalp, and sacral region Historically, colloquial terms such as “stork bite” (nape) and “angel kiss” (forehead/glabella) referred to nevus simplex lesions in particular anatomical regions. Unlike PWS and most other vascular malformations, most nevus simplex lesions regress within the first 2 years of life Clinical differentiation of nevus simplex from PWS, especially on initial presentation, can be difficult. Lesions with lighter pink color, midline location, and indistinct borders favor nevus simplex. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5615389/

suckitnbme  I agree that this nevus simplex and not a strawberry hemeangioma. Of note, nevus simplex lesions are flat lesions formed from dilated capillaries. Lesions on the face tend to regress while lesions on the back of the neck typically do not. https://en.wikipedia.org/wiki/Nevus_flammeus_nuchae +1  
misterdoctor69  The main thing that bothers me about this question is that if it is indeed nevus simplex, it's definitely a very non-typical presentation. Nevus simplex most commonly occurs on he back of the neck/midline locations plus they are pink in color. The lesion described in this question is purplish (not pink) and it appears on the right side of the face (ie. neither back of neck nor midline). We can definitely rule out nevus flammeus because that is only seen in the setting of Sturge-Weber syndrome, which this patient has no signs of. We can also rule out strawberry hemangioma because such a lesion would be raised, not flat. +2  



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fenestrated  nbme23* +1  
madden875  Your answer is incorrect; it's not a strawberry hemangioma. one of the biggest points of difference is that a strawberry hemangioma is raised or nodular, but this patient presents with a flat lesion. This presentation is more representative of a nevus simplex. Boards and Beyond describes this well. +  



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kateinwonderland  Me too! TABLE 1 Classification of Vascular Lesions Vascular malformations (flat lesions) -Salmon patch (also known as nevus simplex or nevus telangiectaticus) -Port-wine stain (also known as nevus flammeus) Hemangiomas (raised lesions) -Superficial hemangioma (also known as capillary nevus hemangioma) -Deep hemangioma (also known as cavernous hemangioma) https://www.aafp.org/afp/1998/0215/p765.html +  
krewfoo99  Because they describe the lesion as cavernous vascular channels +  
covid2019  After looking into it, port wine stain comes as part of Sturge Weber SYNDROME. Given that this child was coming in for a well-child examination, they're implying there's no other symptoms (SWS would have signs of other vascular malformations like in the CNS--> epilepsy). +  



"purplish" is a frustrating word here but they key is CAVERNOUS VASCULAR CHANNELS. Port wine stain in sturge weber and salmon patch ("stork bite") are both flat lesions, not a hemangioma.

sunshinesweetheart  outcomes: stork bite/salmon patch will regress by 5-6year old or persist into adulthood; strawberry hemangioma will regress by 3-6 year old; port wine stain will regress or persist but it'll be associated with the sturge-weber stuff see the mnemonic pg 513 of FA 2019) +  
sunshinesweetheart  oops correction on port wine stain outcome: "lesions become a deeper purple, and angiomatous bleeding papules and soft tissue hypertrophy often develop. Because of the propensity of these cutaneous lesions to persist and grow, treatment of cosmetically or functionally impairing port-wine stains is recommended during infancy to prevent the soft tissue and bony changes" from the link kateinwonderland posted above +  



 +0  upvote downvote
submitted by melanoma(5),

strawberry hemangioma: capillary hemangioma consist on thin walled blood vessels filled with blood and separated by conective tissue. cavernous hemangioma: LARGE dilated vascular spaces this is the difference




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shaeking  A strawberry hemangioma is normally pink or red (which is why it is named strawberry). The description has a flat purplish lesion which makes me think of a port wine stain on the face. How do you know to think of strawberry hemangioma over port wine based on this question stem? +1  
sheesher  This sounds more like a nevus simplex, which is very similar to a port wine stain, though it regresses over time. +2  
seagull  the age is key here. Newborns have strawberry hemangiomas typically on their face. Sturge-Weber could also be the case but none of the answer choices matched to that description. +1  
vshummy  I would agree with Sturg Webber nevus flammeus but I also noticed First Aid says it's a non-neoplastic birth mark so I should have known not to pick malignant degeneration or local invasion. Also because capillary hemangiomas don't have to be flat but the nevus flammeus is consistently flat. But I'm also reading on Wiki that the nevus flammeus doesn't regress so they must be trying to describe strawberry hemangioma even though I don't agree with their color choice... +  
nala_ula  Maybe (and I can only hope I'm right and the test makers are not -that much of- sadists) they would have made sure to write "in a cranial nerve 5 (either ophthalmic or maxillary) distribution" if it were Sturge-Weber. +1