Metastatic Dissemination of a Neuroblastoma

A 4-year-old boy presented with a history of proptosis, periorbital ecchymosis ("raccoon eyes"), weight loss, headache, and vomiting for 2 months. On clinical examination, he presented with periorbital ecchymosis, subconjunctival hemorrhage (Figure 1), proptosis, and stiff neck. No other abnormality was found. The findings of a lumbar puncture were normal. Laboratory tests showed anemia and elevated alkaline phosphatase, phosphorus, and lactate dehydrogenase levels. Computed tomography (CT) of the brain showed a lobulated periorbital mass involving the roof and lateral wall of the left orbit, and "hair-on-end" spiculated periostitis of the orbits, sphenoid wings, and skull associated with bone destruction and irregular sutural diastasis (Figure 2; available at www.jpeds.com).

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