Neonate presents with swelling of breast
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A 19-day-old female neonate presented with a 1-week history of mild swelling of the left breast, with some erythema and a small scab.
Her primary care provider cultured a small amount of fluid from under the scab, over the nipple area, with results pending. She was then sent home with a prescription for oral clindamycin pending follow-up in 48 hours for culture results and a progress report. However, even though the baby was nursing well, she was spitting up much of the clindamycin. On follow-up, the swelling and erythema had dramatically worsened, and she was sent for admission. Her past medical history included a normal pregnancy, labor and delivery. The only notable feature at birth was mild bilateral physiologic breast enlargement.
Examination on admission to the hospital reveals normal vital signs, mild physiologic breast enlargement and left breast erythema and swelling (Figure 1), with what appeared to be small pockets of white material showing through the thin, overlying skin of the nipple area. Additionally, there appears to be a blistering rash in the right groin with discrete, scattered, small pustules and remnants of blisters on patchy, erythematous skin about the area (Figure 2). The rest of her exam was normal.
What’s your diagnosis?
A. Group A strep mastitis with scarlatiniform rash
B. Escherichia coli breast abscess with drug reaction
C. Multifocal cutaneous herpes simplex virus infection
D. Breast abscess and inguinal pyoderma due to Staphylococcus aureus
Answer and discussion:
The patient was taken to the operating room by pediatric surgery for incision, drainage and culture (Figure 3), carefully avoiding injury to the breast bud.
The culture grew Staphylococcus aureus (answer D) that was methicillin- and clindamycin-sensitive (MSSA). After initial treatment with IV clindamycin, treatment was continued with IV cefazolin for 3 days, and the patient was then transitioned to oral cephalexin to continue treatment at home, with complete clearance of the breast infection as well as the inguinal pyoderma. The baby was likely heavily colonized with MSSA. With pustular, blistering lesions, the S. aureus responsible for this pyoderma was likely a strain that produces epidermolytic toxin causing the blistering in places.
The possibility of group A streptococcus (GAS, or Streptococcus pyogenes) is much less likely but possible. GAS is more likely to result in more rapid progression of cellulitis or possible erysipelas with less likely abscess formation, and it does not produce blistering lesions. GAS infections may also be accompanied by a scarlatiniform rash, which is uncommon in neonates (Figure 4) because many mothers pass along antibodies to their babies against GAS strains that produce streptococcal pyrogenic exotoxins responsible for the rash. When seen, the characteristic rash consisting of “multiple erythematous, blanchable papules and patches of erythroderma, forming the ‘sandpaper’ eruption of scarlet fever,” according to Chapter 24 of Pediatric Dermatology, 3rd edition. As noted, the patient in this case had pustules and blisters, most consistent with S. aureus pyoderma.
Escherichia coli, while a common cause of neonatal infections, it is not a common cause of breast abscesses or other soft tissue infections. Regarding a drug-induced rash, in addition to being rare in neonates, the baby was taking no drugs when the problem started. Lastly, multifocal cutaneous herpes simplex virus infections would be expected to produce discrete lesions consisting of pustules and vesicles with mostly normal surrounding skin. When multiple lesions coalesce, an irregular, larger lesion occurs and may not be recognized as a typical HSV lesion (Figure 5). It should not resemble a large, pyogenic abscess.
Reference:
- Darmstadt GL. Streptococcal and staphylococcal Infections. In: Schacher LA, Hansen RC, eds. Pediatric Dermatology. 3rd ed. Mosby; 2003:1006-1007.
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Brien is a member of the Healio Pediatrics and Infectious Disease News Editorial Boards, and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.