A case report of an unexpected traumatic brain injury following severe child abuse

Introduction Child abuse can have several definitions, but in general, it refers to practicing or allowing others to commit physical, emotional, and sexual harm and also cause physical and emotional pain to a child (1). This form of maltreatment can be observed in all human societies regardless of skin color, race, and sociocultural levels; characterized by a wide spectrum of psychological symptoms such as anxiety, depression, increased risks, suicidal behaviors, and physical problems induced by trauma, malnutrition as well as deficient growth (2). According to the United States Department of Health and Human Services (HHS), 2.5 million cases of child abuse were reported in 2009 including 3 700 000 children. In this respect, 80% of child abuse cases were practiced by parents and 1770 children consequently lost their lives (3). Based on the report released by the World Health Organization (WHO) in 1999, approximately 40 million 0–4-year-old children worldwide had been at the risk of abuse and neglect by their parents or caregivers, to an extent that they required the use of social and healthcare services (4). The present study was a report on a case of physical and sexual child abuse accompanied by traumatic brain injury (TBI) referred to an emergency department.

ensure that the cervical spine was immobilized. There were symptoms of light bleeding in the frontoparietal region that were packed. The consciousness level was evaluated by 13 out of 15 based on the GCS, the pupils had diminished and they were reactive, and there was no obvious neurological impairment. In terms of descriptions provided by parents, each one had a different account of the cause of the trauma and there was no consistency between them. The child had no history of illnesses, allergies, or medication use. In the secondary examinations and additional clinical investigations, a 3.5-cm laceration in the right peritoneum with hematoma in the same area was observed. Following the examination of the genital organs, there were abrasions in the internal part of the left femoral region with passive genital hemorrhage and the anal region was unharmed. According to the pattern of the child's admission to the emergency department, paradoxical accounts by parents, clinical examinations as well as TBI pattern of the child; the probability of a child abuse was raised. Following the brain CT scan, the symptoms of fracture of the right frontoparietal region and also the fracture of the occipital bone on the same side with a mild epidural bleeding in the right peritoneal region were seen without midline shifts ( Figure 1). Other graphs and CT scans including CT-scan of the neck ( Figure 2) as well as the radiography of the chest and the pelvic cavities ( Figure  3) also led to no acute points. Thus; neurosurgery, legal medicine, gynecology, and surgery consultations were requested. In terms of consultations with legal medicine, evidence of a suspected case of sexual abuse was confirmed, and samples were taken from head hair, mouth, vagina, and anal region. Diagnostic tests for AIDS and hepatitis were also requested. Consulting with a gynecologist, the chance of the hymen break was verified through examination under anesthesia. The patient was also referred to a pediatric psychiatrist for counseling and psychiatric services as well as post-traumatic injury control. Finally; 20 days later, the child was discharged from the pediatric ward with good medical care. Counseling and psychiatric services also lasted for one year.

Discussion
Physical, emotional, and sexual abuse and neglect are four important types of child abuse (5). In the present case study, the reported child abuse accompanied by severe physical and sexual injury was confirmed by examinations. In a study in the United States on 664 cases of blunt abdominal trauma, it was reported that, with the exception of car accidents, 41% of the cases were suspected with child abuse (6). In the present case study, the examination of the abdomen did not reveal a new point. Ross et al in their study on adolescent abuse in Chinese families in Hong Kong also reported that the prevalence rate of physical abuse was 28.9%; accordingly, the prevalence rate of mild violence was 11.2% and 16.9% in girls and boys, respectively (7). Other studies had similarly documented the prevalence rate of 3 deaths per day due to child abuse; of which, 70% were reported following injury to the head   and the neck (8,9). In the present case study, there were symptoms of light bleeding and head trauma in the right frontoparietal region. Generally, according to statistics and figures released for child abuse worldwide and those in Iran, child abuse has not been fully reported for various reasons such as different attitudes and beliefs towards child abuse among individuals, no reporting of child abuse cases by parents due to fear of legal prosecutions, children's low age, and assuming child abuse as a routine issue as well as a sense of loyalty to parents by children (10). Therefore, it seems that there is a need to raise awareness in relation to child abuse symptoms and its accompanied risks. The medical staff is also required to precisely consider child abuse symptoms including accounts by parents and those by children as well as accurate and systematic physical examinations, since they may be neglected in a busy emergency department.

Conclusion
In the present case study, the child was seriously examined and followed up. We must always consider child abuse in contradictory descriptions by parents, and when the clinical findings do not match to mechanism of injury. These patients need careful attention and serious followups and psychiatric consultations.

Authors' contributions
Case presentation: SRH, MF. Analysis and interpretation of data: EB, MF. Drafting of manuscript: All authors. Critical revision: MF.

Ethical Issues
The written consent form was obtained for this report.