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2-month-old male with unusual blistering rash in the diaper area
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A previously healthy, 2-month-old male is admitted to the hospital with an unusual blistering rash in the diaper area. The onset was a few days earlier, but since then, additional lesions have developed. There has been no fever reported or other concerning symptoms, such as nausea, vomiting, diarrhea, coughing or any other rash or skin findings. The baby’s appetite is normal and unchanged, and there have been no sick contacts. He is on no medications.
Exam upon arrival revealed a healthy-appearing 2-month-old male with normal vital signs. The only positive finding was a cluster of four discrete lesions of various sizes (Figure 1). One of these was raw and appeared to previously have been a blister, and the remaining three were smaller, blister-like lesions that contained yellowish fluid. Additionally, there were a few very small erythematous papules mixed within the same area, located on the lower abdomen, right proximal medial thigh and suprapubic area.
What’s your diagnosis?
A. Herpes simplex dermatitis
B. Bullous impetigo
C. Candida diaper dermatitis
D. Staphylococcal scalded skin syndrome
This is a straightforward case of bullous impetigo (choice B). This is much more likely to be seen in the primary care clinic than in the infectious disease clinic because it is not much of a diagnostic dilemma. The reason it got some attention was because of the baby’s age and a slight degree of uncertainty. One of the lesions was unroofed and sampled for culture and Gram stain, revealing Gram-positive cocci and grew methicillin-sensitive Staphylococcus aureus (MSSA). Two things have to happen for this to develop: first, there has to be colonization of the skin of the area with MSSA, and second, there has to be some injury or damage to the microstructures of the skin. If S. aureus could invade through healthy, intact skin, we would all appear to have Jb syndrome. In a diaper-wearing baby, the skin oftentimes becomes damaged due to prolonged contact with urine and/or feces. In older children, it may be simply a mosquito bite or other minor break in the skin that may go unnoticed. In patients with underlying skin problems or acute infection such as varicella-zoster virus (chickenpox), a secondary infection with S. aureus can easily occur, resulting in bullous varicella in the case of chickenpox (Figure 2). In order to produce these bullous lesions, the S. aureus has to be a strain that produces one of the epidermolytic toxins locally. If there is a S. aureus infection with one of these toxin-producing strains, and toxin is released into the bloodstream, it results in staphylococcal scalded skin syndrome (Figure 3).
Herpes simplex virus (HSV) infections in this area occasionally occur, and they are usually not difficult to distinguish by the characteristic clustering of vesicles (Figure 4). In such cases, it is important to at least consider the possibility of child abuse, and to document the cause by obtaining an HSV PCR of one of the lesions.
Lastly, Candida diaper dermatitis can take on many appearances, but when severe, there will be some moist, beefy-red skin, with satellite lesions (Figure 5), from which the yeast can be recovered by culture.
- For more information:
- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, and an adjunct professor of pediatrics at 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.
Columnist comments: On Nov. 23 and 24, the 32nd Annual Infectious Diseases in Children Symposium will take place at the Sheraton New York Times Square Hotel. This will be my 27th year to be a part of this high-quality meeting, and I know many of you are frequent fliers as well. For those new to this meeting, it is a great time to visit New York City, and perhaps stay for Thanksgiving. As in years past, I will be doing a two-part live version of this column on both Saturday and Sunday, presenting 10 new cases. I hope to meet you there.