Nodular fasciitis is a benign proliferation of myofibroblast often misdiagnosed as a sarcoma of soft tissues. It is characterized by rich cellularity, mitotic activity and rapid growth. It is usually solitary, and occurs in the head and neck in childhood, and upper extremities in adulthood. We report the case of a four-year-old child who developed multiple lesions in the head, neck and trunk. Nodular fasciitis was diagnosed in this reported case by incisional biopsy. Case ReportA four-year-old Sudanese boy presented with a two-week history of a painless scapular mass, which was progressively increasing in size and was associated with moderate restriction of right arm movement. His father denied any history of trauma. The patient had a history of bilateral halux valgus, which had been corrected two years previously. He was a product of a spontaneous vaginal delivery and had no family history of a similar problem. The result of clinical examination showed a 5x10 cm firm mass at the angle of the right scapula fixed to underlying muscle. The area was not tender to palpation, had no warmth or erythema, and the overlying skin was freely mobile. There was limitation of abduction up to 70°, and restriction in bending forward due to a bulky right paraspinal muscle Initial laboratory findings revealed the following: WBC count, 8.2x10/L; ESR, 7 mm in the first hour; creatine kinase, 169 U/L (normal, 25-200 U/L); alkaline phosphatase, 455 U/L (98-279 U/L); and calcium level of 10.46 mg/dL (8.1-10.4 mg/dL).The radiological evaluation of the patient included a chest x-ray (Figure 1), which showed right-sided chest wall swelling mainly at the scapular region. The opacity was homogenous, with no calcification or bony lesion. Enhanced CT scan showed slightly infiltrating mass of soft tissue density among muscles of the right shoulder and chest wall. Fine-needle aspiration was inconclusive. The patient was taken to the operating room, and incisional biopsy was performed under general anesthesia. At surgery, there was no line of demarcation between the subcutaneous tissue, tumor and underlying muscle. Therefore, a wedge biopsy was taken, including subcutaneous tissue and muscle. Closure was performed in the usual fashion.The patient was discharged home while awaiting histopathology report. Microscopic examination of the biopsy demonstrated a sparsely cellular lesion, composed of immature, plump and slender fibroblasts in a loose background, and containing extravasated red blood cells and rare inflammatory cells, particularly mast cells. The fibroblasts were haphazardly arranged, relatively uniform in size and shape, and had oval pale staining nuclei, with prominent nucleoli and rare mitotic figures. These cells resembled fibroblasts seen in tissue culture ( Figure 2). Residual skeletal muscle fibers were seen within the lesion, which indicated infiltration of the surrounding skeletal muscle. These microscopic features were consistent with nodular fasciitis. The child was seen in the outpatient clinic one week after the operation....

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