A 2-year-old boy was brought to the emergency room of Columbus (Ohio) Children's Hospital by his parents who stated that they had noted a gradual onset of left periorbital and frontal swelling during the past three days. Medical history was noncontributory, except for intermittent vomiting, for which he had been previously admitted to the hospital. The family history was unremarkable, except for the death of a sibling caused by sudden infant death syndrome.
Physical examination showed an alert, oriented, afebrile child in apparent good general health. There was severe edema with ecchymoses in the left facial and orbital areas. The left ear was edematous, the tympanic membrane was dark, and a positive Battle's sign was noted. Multiple areas of skin discoloration were seen over the trunk and extremities. The complete blood cell count and urinalysis findings were normal. Roentgenograms of the chest, abdomen, pelvis, cervical spine, and skull and computed