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3-week-old presents with rapidly spreading erythematous annular lesions
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Heidi Moline
James H. Brien
A 3-week-old boy presents with a one-week history of a rash, which began on his head and rapidly spread. He has otherwise been well with no fever, fussiness or lethargy. He is feeding normally with no other significant problems noted.
The mother received good prenatal care, with all screening tests being negative/normal, and uncomplicated pregnancy, labor and delivery. His newborn physical exam was essentially normal. There were no abnormalities on his newborn screens, and no skin abnormalities seen then or at his one-week follow up. The mother is healthy, but has a history of pulmonary tuberculosis, for which she had completed treatment. The family lives in a shelter, including nine other siblings who are healthy. Both parents are African immigrants and have been in the country for two years, with no recent travel history or animal exposure.
On exam, the child appears clinically stable and comfortable. There are 11 erythematous annular lesions on the face (Figure 1), scalp, right arm, right leg (Figure 2) and penis. The center of the lesions showed fine scales without atrophy. A few larger lesions showed pustules at the circumference, filled with yellowish fluid; the lesions vary in size from 1 cm to nearly 5 cm, without nail involvement.
Figure 1. Child at presentation.
Source: Brien JH
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Figure 2. Child at presentation.
Source: Brien JH
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Case Discussion
A skin scraping of the lesions with potassium hydroxide (KOH) preparation was consistent with Trichophyton rubrum (D. Tinea corporis). Upon examination of the mother, she was found to have extensive ring lesions across her arms (Figure 3) and chest; the patient’s 2-year-old sibling had a similar infection, though more extensive (Figure 4). The sibling tested positive for T. rubrum as well, but required oral itraconazole as the child did not initially improve on topical clotrimazole. The child presented above was treated with topical 1% clotrimazole twice daily, with a good response, as shown in Figure 5, six weeks later; to date, this is the youngest U.S. reported neonatal case of extensive tinea corporis.
Figure 3. Mother’s arm on day of child’s presentation.
Source: Brien JH
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Figure 4. Child’s sibling prior to treatment.
Source: Brien JH
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Tinea infections rarely occur during the neonatal period, but have been reported. In fact, there was a report of an outbreak of six cases in a level II neonatal ICU that was traced back to a single provider. These infections can affect any area of skin, hair and nails, and are progressive unless treated. Diagnosis can be established with a KOH wet mount of skin scrapings, use of a dermatophyte test culture medium (DTM), or 16S ribosome testing. Treatment is often difficult due to the likelihood of re-infection and the length of therapy required for cure. Topical application of miconazole, clotrimazole or terbinafine (>4 years) can be used.
Though this child responded well to topical application, in the case of widespread or persistent dermatophytoses (as in his older sibling), systemic treatment may be necessary. Trichophyton rubrum is a dermatophytic fungus in the phylum Ascomycota, class Euascomycetes. It is an exclusively clonal, anthropophilic saprotroph that colonizes the upper layers of dead skin, and is the most common cause of athlete’s foot, fungal infection of the nail, jock itch and ringworm worldwide. Patients usually improve in 4 to 6 weeks. This case also illustrates the importance of screening and treatment of family members and close contacts. Close contact with others, such as in a shelter, can easily promote spread.
Figure 5. Child following treatment with topical clotrimazole.
Source: Brien JH
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Neonatal lupus erythematosus is seen in patients in the first few weeks of life, and can be present at birth. These lesions are typically limited to the face, and resolve spontaneously after several weeks. Management of these patients should be focused on early identification with early anti-Ro/anti-La antibody testing to expedite cardiac testing.
Hansen disease is rare among children in the United States. However, it does affect children across the globe, and though rare in infants, several cases among children younger than age 1 year have been reported. Infants born to mothers with the disease who have not received treatment are at a high risk for contracting the disease via skin-to-skin or droplet transmission.
Annular erythema of infancy is a nonpruritic eruption that typically occurs in otherwise healthy infants in the first 2 weeks to 6 months of life. The etiology is unknown, and the lesions disappear spontaneously, often in as little as 24 to 48 hours, but patients may have recurrences every few weeks.
For a review of a case of tinea capitis in a 2-week-old infant caused by Microsporum canis, I refer you to my October 2012 column. Also, a case of Hansen disease can be found in the November 2015 issue.
I would like to thank Heidi Moline, MD, MPH, a first-year pediatric resident at the University of Minnesota, for putting this case together, under the guidance of Stacene Maroushek, MD, PhD, MPH, a pediatric infectious disease specialist with at Hennepin County Medical Center in Minneapolis, Minn., and a faculty member in the division of global health in the department of pediatrics at the University of Minnesota.
- Reference:
- Snider R, et al. Pediatr Infect Dis J. 1993;12(2):145-148.
- 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.