Pamidronate as treatment of severe hypercalcemia in SCFN of the newborn: A case report

Abstract

Subcutaneous fat necrosis of newborn (SCFN) is an uncommon entity that occurs in neonates who experienced perinatal stress. We report use of pamidronate, to control persistent hypercalcemia in a 5- week-old infant with SCFN not responding to initial treatment. A term male neonate was born by emergency LSCS due to non-reassuring fetal status. Antenatally mother had gestational diabetes mellitus, group B streptococcus carrier and an antenatal scan at 29 weeks detected a fetus with dilated small bowel. Baby was born vigorous but complicated with bowel perforation requiring fluid resuscitation and a bedside glove drain. He underwent laparotomy for small bowel perforation secondary to ileal atresia and required TPN postoperatively. At 1 month of life, he had palpable purplish lumps at his trunk and limbs associated with severe hypercalcemia supporting the diagnosis of subcutaneous fat necrosis. Despite receiving initial treatment of hyperhydration and frusemide for two weeks, the patient's hypercalcemia peaked to 4.11mmol/L. His renal ultrasound showed nephrocalcinosis with renal and bladder calculi. He was given IV Pamidronate. Post single dose of IV Pamidronate, calcium levels reduced ranging 2.2-3 mmol/L and frusemide was discontinued. On discharge he was maintained on low calcium milk. During his first follow up the calcium level remained stable and repeated ultrasound showed resolution of the renal pelvis and bladder calculi with persistence of the medullary nephrocalcinosis. SCFN has a potentially life-threatening complication due to development of severe hypercalcemia. For patients with severe hypercalcemia not responding to hydration, and low calcium intake, pamidronate is an effective and safe treatment.  Good supportive management is very important and should be done prior to pamidronate.