Subcutaneous Nodules in a 28-week-old Girl

A 28-week-old girl in the pediatric cardiovascular intensive care unit (PCICU) is evaluated for broad areas of subcutaneous nodules and firm, indurated plaques. The patient, born at 39 week’s gestation via cesarean delivery, has an extensive medical history that includes hypoplastic left heart syndrome status-post Norwood procedure complicated by pulmonary hemorrhage and a 2-week course of extracorporeal membrane oxygenation, and pulmonary hypertension. She was admitted to the PCICU 1 month earlier for pre-Glenn evaluation. Examination at that time was notable for increased work of breathing, a 2/6 holosystolic murmur at the middle left sternal border, a crusted lesion on the left forearm, and multiple firm nodules on the extremities. Two days after admission, due to hypoxemia, she was taken for a diagnostic catheter, where she had 2 stents placed and a coarctation balloon angioplasty. This was complicated by oxygen desaturation and bradycardia requiring epinephrine. She remained intubated for 5 days...