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A nine-month-old girl was seen for
failure to thrive and bruising around the eyes. On physical
examination, she was noted to have periorbital ecchymosis,
dysconjugate gaze, dilated and fixed pupils, and an abdominal
mass. Examination of an open-biopsy specimen of the abdominal
mass revealed neuroblastoma. A photograph of the child's face
(Panel A) shows bilateral periorbital ecchymosis ("raccoon
eyes") with dysconjugate gaze; the sclera appear normal. An
axial T1-weighted, contrast-enhanced magnetic
resonance image of the brain through the orbits (Panel B) shows
an extensive metastasis at the skull base, involving the
sphenoid bone and the temporal and zygomatic bones bilaterally.
The characteristic "raccoon eyes" appearance
associated with neuroblastoma and metastasis to the skull is
probably related to obstruction of the palpebral vessels
(branches of the ophthalmic and facial vessels) by tumor tissue
in and around the orbits (arrows, Panel B). The correct
diagnosis of this condition is sometimes delayed because of
workup for child abuse or trauma.
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