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A 7-week-old female presents with severe rash as only symptom
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A 7-week-old female is referred to your pediatric clinic for evaluation of a severe rash. She has been seen three times by her primary in the past 14 days for treatment of this rash; first with nystatin, then clotrimazole, then econazole nitrate spectazole topical creams without notable improvement. There has been no fever, vomiting, diarrhea or cough, but she has been a bit fussy with the application of the creams. Her appetite and activity have remained normal for her age.
Her medical history is that of a term baby from a normal pregnancy, with labor and delivery being complicated by maternal fever, resulting in her being treated empirically with ampicillin and gentamicin pending cultures, and was discharged on day 3. It is unclear when the skin condition was first noted, but it was sometime between the second and third week of life, suddenly becoming worse around week 4.
James H. Brien
Her immunizations include only the first dose of hepatitis B vaccine. Family history is positive for mother and maternal grandparents having mild, intermittent asthma, but is otherwise unremarkable. There are many extended family members living in the household, but no one has any chronic or acute skin condition. The father is an active-duty soldier currently deployed to the Middle East, but had been home briefly soon after the baby’s birth. There are no pets or smoke exposure and no sick contacts.
Examination reveals a robust, healthy-appearing 7-week-old infant female with normal vital signs. The only positive finding is a generalized maculopapular, oily rash with areas of scaling and intense, wet erythema in the folds of skin under the neck, axillae, behind the ears and diaper area (Figures 1 to 4).
Source: Brien JH
Examination reveals a robust, healthy-appearing 7-week-old infant female with normal vital signs. The only positive finding is a generalized maculopapular, oily rash with areas of scaling and intense, wet erythema in the folds of skin under the neck, axillae, behind the ears and diaper area (Figures 1 to 4).
A CBC done prior to being referred revealed 27,600 WBCs with 46% granulocytes and 48% lymphocytes.
What’s Your Diagnosis?
A. Seborrheic dermatitis with secondary candidiasis
B. Bacterial cellulitis
C. Contact dermatitis
D. Eczema herpeticum
Hint: A swab of the area of most intense erythema grew 2+ Staph aureus, 3+ group A strep and 3+ Corynebacterium species, but failed to grow any fungus.
This is a case of an infant with seborrheic dermatitis that is secondarily infected with Candida albicans (A), with the characteristic wet, beefy red appearance and satellite lesions. If one were to culture one of the satellite lesions, C. albicans would be recovered. But the natural tendency is to sample the area of greatest erythema, which may recover a variety of colonizing organisms, but not likely the Candida, as in this case, according to William Weston’s textbook, Color Textbook of Pediatric Dermatology. The negative fungal culture can be misleading, resulting in delaying the antifungal treatment needed. However, the strep or the staph could be aggravating the condition, much in the same way that they may complicate severe atopic dermatitis by increasing the inflammation, but not likely to develop into cellulitis, which would have a different appearance (Figure 5), with more swelling and dry erythema, often with a nearby break in the skin and frequently with abscess formation (Figure 6).
The strep or the staph could be aggravating the condition, not likely to develop into cellulitis, which would have a different appearance (Figure 5). With more swelling and dry erythema, often with a nearby break in the skin and frequently with abscess formation (Figure 6).mauris, tincidunt tincidunt lorem lobortis cursus. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Integer commodo placerat fermentum.
I have had similar cases of severe candidiasis, in which bacterial culture failed to recover the Candida unless taken from a satellite lesion, such as the case in Figure 7. In both of these cases, the WBC counts were elevated, but neither was treated with antibacterial agents, only oral fluconazole (Diflucan, Pfizer) and topical skin care, including steroid cream and good hygiene, with a good and rapid responses (Figures 8 and 9: 3 days after starting therapy; note biopsy site in axilla). Because of the severity, a biopsy was done to rule out Langerhans cell histiocytosis. These cases usually have a startling effect on the parents and provider due to their dramatic appearance, but they can usually be managed in the clinic. However, if there’s concern for sepsis, especially in a young infant, obviously one should admit until sepsis can be ruled out.
Figure 7. Bacterial culture failed to recover the Candida unless taken from a satellite lesion, such as the case in Figure 7.
Figures 8 and 9. 3 days after starting therapy; note biopsy site in axilla.
Contact dermatitis, such as with poison ivy, will result in swelling and erythema, but not as likely to be as bright red and wet with satellite lesions (Figure 10), and only occurring in the areas of contact with the offending agent. Technically speaking, the case presented started out as a contact dermatitis, as do virtually all cases of diaper rashes, and significant overlap in appearance can occur.
Contact dermatitis, such as with poison ivy, will result in swelling and erythema, but not as likely to be as bright red and wet with satellite lesions (Figure 10). The herpes virus will invade anywhere there is skin injury, as shown in Figure 11.
Eczema herpeticum is an opportunistic viral infection of damaged skin, much like C. albicans. The herpes virus will invade anywhere there is skin injury, as shown in Figure 11. These cases almost always need to be treated with IV acyclovir (APP Pharmaceuticals) in a hospital setting in the initial days, as the potential for severe progression is great. After the lesions show good crusting and no new vesicles appear, one can safely change over to oral therapy with close outpatient follow-up.
References:
Weston WL, Lane AT, Morelli JG, eds. Color Textbook of Pediatric Dermatology. 4th ed. Melville, New York: Elsevier Health Sciences;. Melville, NY. May 2007.For more information:
James H. Brien, DO, is a member of the Infectious Diseases in Children Editorial Board, as well as Vice Chair for Education at The Children’s Hospital at Scott and White, and is the Associate Professor of Pediatrics at Texas A&M University, College of Medicine, Temple, Texas, can be reached at jhbrien@aol.com.Disclosure: Brien reports no relevant financial disclosures.