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An 11-month-old boy with widespread rash
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An 11-month-old boy is referred from a local hospital ED for evaluation of a widespread rash, consisting of hundreds of papules, pustules and some vesicles with a generalized distribution from face to foot. The onset was initially seen on both forearms several weeks earlier. During that time, he had three visits to the ED. The first two evaluations concluded that he had eczema and was prescribed Eucerin (Beiersdorf Inc.), a urea-containing moisturizer. However, the rash seemed to spread dramatically, especially in the past few days, along with some subjective fever the day before admission. In the ED, his temperature was 105°F, and because he had numerous pustules, he had a blood culture obtained and was given a dose of ceftriaxone before transfer.
James H. Brien
His medical history is that of a generally healthy infant who has only had occasional wheezing problems. His immunizations are up-to-date. His family history is positive for some atopy with asthma and atopic dermatitis. There are no sick contacts, but his parents report having some itching about their hands.
On examination, he is afebrile but irritable with intense itching, and he seems to be in pain at times while frequently scratching at the rash. His rash consists of hundreds of papular and pustular lesions from face to foot (Figures 1 and 2), with extensive excoriation about the thighs with patches of underlying erythema (Figure 3). The rest was unremarkable. His admission white blood cell count was 24,100/mm3. The blood culture is pending.
His rash consists of hundreds of papular and pustular lesions from face to foot (Figures 1 and 2).
Source: Brien JH
His rash consists of extensive excoriation about the thighs with patches of underlying erythema (Figure 3).
What’s Your Diagnosis?
A. Atopic dermatitis
B. Eczema herpeticum
C. Scabies
D. Hand-foot-mouth disease
Several hints exist that point toward scabies; intense itching, lack of response to other treatment and both parents have typical lesions (Figures 4-6), with Figure 5 showing some tracking adjacent to the papule and mother’s hand with several pruritic papules.
Extensive cases like this can be confusing, especially when the skin is badly damaged by scratching and secondarily infected. Although the patient had no fever in the hospital, he was highly febrile at the referring ED and the elevated white blood cell count raised some concern. Although his blood culture at our lab was negative, the one obtained at the referring ED was eventually reported positive for group A streptococcus. Apparently, there was some difficulty isolating the organism because the culture was not final until a couple of days after the child had been discharged.
Hints that point toward scabies include intense itching, lack of response to other treatment and both parents have typical lesions (Figures 4-6).
Figure 6.
The antimicrobials received included a dose of ceftriaxone and IV clindamycin in the ED. The IV clindamycin was continued until he was discharged about 48 hours later on oral clindamycin. Since his repeat blood culture was negative and he remained afebrile and doing well upon learning of the culture, he was continued on oral clindamycin to finish a 10-day course and did well. The group A strep, no doubt, was contributing to the pyoderma on his left thigh, and maybe other isolated areas as well.
The recommended treatment is usually 5% permethrin cream applied to entire skin surface for 8 to 14 hours, and then washed off. Because his scabies was so widespread, the decision was made to use 200 mcg/kg Ivermectin orally as a single dose, and repeated 1 week later to eradicate newly hatched scabies that survived the first treatment, with good results. The parents were treated with 5% permethrin cream and instructions for environmental eradication per the Red Book recommendations.
The damaged skin can also be a rich source for opportunistic herpes simplex virus infection, which can be severe (Figure 7).The viruses of hand-foot-mouth disease can result in cutaneous dissemination in those with underlying skin disease, such as severe atopic dermatitis (Figure 8).
Other treatment options include 1% lindane, leaving it on the skin for 8 to 12 hours, and 10% crotamiton applied as per the Red Book guidelines.
Atopic dermatitis is a chronic inflammatory skin condition with severe pruritis, leading to lichenification and frequent infections that may be accompanied by bacteremia with Staphylococcus aureus and group A strep. The damaged skin can also be a rich source for opportunistic herpes simplex virus infection, which can be severe (Figure 7). If eczema herpeticum is diagnosed, the child usually needs hospitalization for IV acyclovir therapy. These children usually have elevated immunoglobulin E levels and frequently have a strong family history of atopy. If the IgE level is in the thousands, the child may have hyper-IgE syndrome, with increased risk for deep pyogenic infections, especially with staphylococcal.
An atypical form of hand-foot-mouth syndrome has been increasingly seen (Figure 9).
Hand-foot-mouth disease is usually a relatively mild, self-limiting febrile infection with an exanthem and mouth lesions caused by coxsackievirus A16. Just like herpes virus, the viruses of hand-foot-mouth disease can result in cutaneous dissemination in those with underlying skin disease, such as severe atopic dermatitis (Figure 8). In recent years, an atypical form of hand-foot-mouth syndrome has been increasingly seen (Figure 9) that is generally more widespread and with more severe skin lesions and systemic symptoms, and caused by coxsackievirus A6, rather than A16. It also may occur in the winter, as opposed to most enteroviruses, which tend to occur in the warmer months. So, be on the lookout this winter.
Columnists Comments
Once again, it’s that holiday time of year. It seems the older I get, the faster we fly around the calendar. But, we are lucky to be getting older. Please keep in your thoughts soldiers, sailors, airmen and Marines who are out in the wilderness of various foreign lands, who won’t be home for the holidays, and sympathy for those whose loved ones will never be home for the holidays. We wish you all a happy and healthy 2014. Please keep in touch.
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Disclosure: Brien reports no relevant financial disclosures.