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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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