This is the fundal appearance of a eleven month-old boy who was admitted by the paediatrician for drowsiness and irritability. He had no previous medical history of note and the blood tests were normal.

a. What is the most likely diagnosis?

Shaken baby syndrome.

This is a type of child abuse resulting from violent shaking. The child is typically less than one year of age. Intraocular haemorrhages are typically bilateral involving the subretinal, intraretinal, preretinal and subhyaloid spaces as well as the vitreous. Fundoscopy is important in the diagnosis as the patient characteristically has absent external and anterior segment signs. The child usually presents with lethargy, vomiting and seizures.

b. Which investigation should be requested?

Brain scan should be requested as the patient has a high incidence of associated intracranial lesions. This may be subarachnoid, subdural haemorrhages or cerebral oedema.

c. What is the differential diagnosis?

The conditions to consider include:

• malignant hypertension
• raised intracranial pressure
• idiopathic thrombocytopaenia
• leukaemia
• trauma

d. What other physical signs may be present?

Other signs of injuries:

• soft tissue injuries such as bruising from gripping
• bone fractures at different stages of healing