This article is more than 5 years old. Information may no longer be current.
Febrile illness, progressive rash in 5-month-old girl
Click Here to Manage Email Alerts
A 5-month-old girl presents to the ED for evaluation of a febrile illness and a progressive rash. The onset of the rash began rather suddenly 4 days earlier at multiple sites, primarily on the left leg, the right side of the face and left side of the trunk, and grew in size (Figures 1-4). The lesions began as small red bumps that quickly grew in number to become large, confluent patches transforming into widespread erosions, scattered about on dry skin. There was no history of discrete vesicles, pustules or blisters being seen.
Figure 1. Onset of rash on the right side of the face.
Source: Brien JH
Click the image to enlarge.
Figure 2. Progressive rash on the left leg and left side of the trunk.
Source: Brien JH
Click the image to enlarge.
Figure 3. Progressive rash on the left leg and left side of the trunk.
Source: Brien JH
Click the image to enlarge.
Figure 4. Large, confluent patches transforming into widespread erosions, scattered about on dry skin.
Source: Brien JH
Click the image to enlarge.
The patient initially had been taken to an urgent care clinic on the day of onset, where she had a temperature of 102°F, and was diagnosed with a skin infection. A swab of one of the lesions was obtained for culture, and the patient was given an injection of an unknown antibiotic, and a prescription for trimethoprim-sulfamethoxazole (TMP/SMX). Over the next 2 days, the fever continued and the rash worsened to its current state; the mother also noted the development of a white coating on her tongue. The child was then taken back to the same urgent care clinic, where she was diagnosed with thrush, and prescribed nystatin and instructed to continue the TMP/SMX. These treatments did not seem to help, and she was taken to the children’s hospital ED, where a blood culture was obtained and a dose of IV clindamycin was given, and she was admitted to the hospital.
The patient’s past medical history is that of a previously healthy 5-month-old infant who has moderately severe eczema that has been managed with topical steroid cream as needed and daily emollient. Mother’s immunizations are up to date, and her pregnancy, labor and delivery were uncomplicated. The baby had a healthy, uncomplicated neonatal course and infancy to this point has been normal. She has had no sick contacts, including anyone with a cold sore or shingles.
Examination in the hospital revealed a fever of 102°F, and the skin lesions noted above. Her mouth actually revealed some ulcerative lesions rather than oral thrush. While the patient was being examined, it was noticed that she began having some unusual posturing, flexing her left leg up and resisting any attempt to move the leg back to a neutral position, with generalized stiffening as well as altered mental status with staring, consistent with left-sided focal seizure activity.
At this point, empiric therapy with ceftriaxone, vancomycin plus acyclovir therapy was begun, and the patient was transferred to the pediatric ICU where a full sepsis workup was completed, including normal cerebrospinal fluid and urinalysis. The patient’s CBC had an elevated white blood cell count. Pending lab tests include cultures of blood, urine, CSF, as well as CSF for herpes and enterovirus PCRs, and herpes PCR on whole blood. Swabs of representative skin lesions were obtained for herpes and enterovirus PCRs, as well as swabs for routine culture.
Case Discussion
The severity of the skin damage made clinical identification of the condition very difficult. However, this turned out to be an unusual case of eczema herpeticum (A), with all herpes PCRs positive for HSV-1 (except for the CSF specimen), including the blood sample, supporting the impression that the patient actually had disseminated herpes simplex infection as well as eczema herpeticum.
The patient appeared to have focal seizures, consistent with herpes meningoencephalitis, however the CSF analysis was normal, as were the MRI with contrast, CT scan of the brain and the video EEG. However, with a positive blood herpes PCR, and no other explanation for the new seizures, the patient received a 21-day course of IV acyclovir for the worse-case scenario, with good results.
Figure 5. Following treatment, the patient exhibited rapid improvement of the skin lesions.
Source: Brien JH
Click the image to enlarge.
Figure 6. Following treatment, the patient exhibited rapid improvement of the skin lesions.
Source: Brien JH
Click the image to enlarge.
Figure 7. Atopic dermatitis with disseminated coxsackievirus.
Source: Brien JH
Click the image to enlarge.
Figure 8. Atopic dermatitis with disseminated coxsackievirus.
Source: Brien JH
Click the image to enlarge.
Figure 9. Atopic dermatitis with disseminated coxsackievirus.
Source: Brien JH
Click the image to enlarge.
Figure 10. Atopic dermatitis with disseminated coxsackievirus.
Source: Brien JH
Click the image to enlarge.
The surface culture from the urgent care clinic was positive for methicillin-sensitive S. aureus (MSSA), and in the hospital, a nasal culture grew both MSSA and Streptococcus pyogenes (group A strep); therefore, the vancomycin and ceftriaxone were replaced with cephalexin. The patient had very rapid improvement of the skin lesions, with no new lesions forming and old lesions quickly drying up (as shown in Figures 5-6). At the end of the patient’s 21-day course of IV acyclovir, she was discharged with appointments made for follow-up with infectious diseases, with the intent of evaluating the patient for an immune deficiency. However, the patient was a no-show on 2 occasions and has been lost to follow-up.
Eczema herpeticum is a long recognized complication of eczema or atopic dermatitis. A similar, although less severe case of eczema herpeticum was presented in the September 2010 column of What’s Your Diagnosis? What makes this case somewhat unusual is that even with careful examination of the entire skin surface, no intact vesicle was ever found – only the erosions that are clearly demonstrated in the pictures. This resulted in significant confusion by experienced hospital staff and required a high index of suspicion, supported by the presence of mouth lesions, to make the proper diagnosis.
We have had similar unusual episodes of eczema coxsackieum in patients with underlying skin disease such as this: one of the more severe cases is shown in Figures 7-8, a patient with severe atopic dermatitis with disseminated coxsackievirus with a positive PCR of one of the vesicles from the ankle. Without these few vesicles, the diagnosis may have been missed. This is the same coxsackievirus that may cause hand-foot-and-mouth disease, which was featured in the February 1998 column.
Certainly, S. aureus pyoderma can complicate atopic dermatitis or eczema, but such widespread involvement is fairly unusual. However, a case of this has also been seen (Figures 9-10 from August 2016 column) in a patient with atopic dermatitis and disseminated bullous impetigo. Lastly, varicella is not likely to occur as long as the mother is immune, as a 5-month-old is still likely to have maternal antibody protection; additionally, there was no apparent exposure.
- For more information:
- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.