Infant presents with paronychia, inflamed umbilicus
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A 14-day-old female was taken to an urgent care clinic with multiple paronychia, involving a thumb and both great toes, that began 5 days earlier.
The baby’s umbilicus was also inflamed, and it had a somewhat foul smell since before the cord was detached 1 week ago. The parents denied any other medical problems with the baby.
The mother’s pregnancy was complicated by genital herpes simplex virus infection during the first trimester, but she tested negative for HSV by PCR shortly before delivery. The family history is also complicated by a household contact (an older sister) who had an episode of stomatitis around the time the mother and baby came home from the hospital. She was clinically diagnosed with herpes stomatitis without testing and treated with acyclovir. There are no other known sick contacts.
Additional history of the current complaint indicates that there had been some blisters noted by the parents on these digits when she was taken to the urgent care clinic. At that visit, the thumb blister and umbilicus were cultured for bacteria, and all three areas were treated with topical mupirocin (Bactroban). On the follow-up visit 2 days later, the thumb culture was noted to be negative, but the umbilicus culture was positive for group A strep (Streptococcus pyogenes). She was then sent for admission for further management.
The baby’s exam on admission is that of an afebrile, active, healthy-appearing neonate, except for inflammation at the terminal end of the right thumb and both great toes (Figures 1 to 3) and the umbilicus (Figure 4). The image in Figure 3, taken on admission, shows the last remaining blister. Treatment was begun with ampicillin, and an HSV IgM antibody was sent. However, when the HSV IgM returned negative 3 days later, an infectious disease consult was obtained. At that time, the “blisters” were no longer intact, only erythema with some redundant blister skin.
Summary:
- The patient is a 2-week-old female neonate with multiple “paronychia” and inflamed umbilicus, previously noted to have a foul smell, all treated with topical mupirocin for 2 days prior to admission.
- Blistering was noted early on but is now gone.
- The mother has a history of vaginal HSV during pregnancy.
- A sibling had recent, clinically diagnosed stomatitis and was treated for HSV.
What’s your diagnosis (management)?
A. Full sepsis workup
B. HSV PCR on blood, cerebrospinal fluid (CSF) and lesions
C. Add acyclovir to the ampicillin
D. All the above
The answer is D, all the above. There are several teaching points in this case. The first is that there should be no delay in performing a sepsis workup and starting empiric therapy in a neonate who may have HSV infection. Even though HSV was never identified, the earlier maternal history, the recent history of a household exposure to a sibling with stomatitis and the clinical appearance of the neonate is compelling. The appearance of a paronychia in a neonate should always raise the suspicion of HSV and be managed accordingly, especially when a vesicle or blister is seen. Sometimes, a cluster of vesicles can coalesce, forming what appears to be a blister (Figure 5, from the J.W. Bass collection). A neonate with any HSV infection, or with reasonable suspicion of infection, should be evaluated with a full sepsis workup, including CSF and serum HSV PCR, as well as testing the skin and mucous membrane, and treatment with acyclovir should be started pending test results.
Disseminated and central nervous system HSV infection in a neonate has potential for devastating outcomes and requires a longer course of therapy than skin-eye-mouth (SEM) infections. This patient was fortunate that she appeared to have only SEM disease. Additionally, there is ordinarily no role for herpes antibody (IgG or IgM) testing in a newborn; IgG is mostly maternal, and IgM may not be reliable or timely.
In this case, the baby also may have had HSV involving the umbilicus, but she had a history consistent with funisitis before the cord detached, with a foul-smelling umbilicus and inflammation of the skin about the cord stump. Funisitis is occasionally present soon after delivery from mothers with chorioamnionitis, but it can be seen any time before the cord detaches, and is often associated with low-grade group A strep infection, mixed with anaerobes in the pocket that is formed between the cord and umbilical skin. In mild cases, this may require nothing more than good hygiene, but many experts recommend at least a single dose of benzathine penicillin with good cleaning of the site. The application of a topical antibiotic may also be effective. In cases where there is erythema beyond the rim, or the erythema appears excessive (as in this case), continued IV ampicillin or penicillin would be appropriate for 7 to 14 days; it’s a judgement call.
In 2002, I made up the term “pseudofunisitis” for cases where mechanical irritation causes erythema about the rim of the umbilicus and mild erythema of the surrounding skin. The most common cause of pseudofunisitis is diapering too tightly over the firm umbilical stump, as shown in the images in Figures 6 and 7, taken less than 24 hours apart.
Certainly, HSV may cause an infection about the umbilicus but would also likely appear with vesicles or evidence of damaged redundant skin or with an impetiginous look. Also, funisitis should not be confused with “true” omphalitis (Figure 8), with spreading abdominal wall cellulitis, which can be rapidly life-threatening. This infection should be treated with broad-spectrum antimicrobial therapy directed against Staphylococcus aureus, coliforms and anaerobes, pending culture results. It may progress to necrotizing fasciitis, requiring aggressive surgical debridement of the spreading infection. It is usually best to consult an infectious diseases specialist for guidance. With good photography, this can usually be done virtually.
Columnist Comments:
Note that the case that goes with Figures 6 and 7 was featured in IDC in November 2002. Also, for similar HSV manifestations, note Figures 9 and 10, taken 48 hours apart on acyclovir, of a neonate in the hospital with SEM HSV, and Figure 11, of an older child with proven HSV on the great toe, resembling the toe of the baby presented in this case.
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Brien 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.