A 3-day-old female infant was transferred to the Scott & White NICU from an outside hospital for an evaluation and treatment of a vesicular rash on her scalp, trunk and inner thighs, first noted on the second day of life. She was born at 39 weeks gestation by C-section for failure to progress. Membranes were ruptured approximately 8 hours prior to delivery. The fluid was clear and Apgar scores were 7 and 9 at 1 and 5 minutes, respectively. The babys blood and urine was cultured because of maternal fever (up to 102° F) and antibiotic therapy begun, but discontinued after 48 hours of negative cultures at the referring hospital. On the day of transfer, the patient was feeding well and vital signs were normal. Maternal cultures and lab tests, including VDRL, hepatitis B and HIV were all negative, and there was no history of maternal herpes simplex virus (HSV) infection.
Physical exam confirmed normal vital signs and revealed a mildly jaundiced infant with an erythematous, vesicular rash in whorl patterns over the parietal and occipital area of the scalp, the trunk and inner thighs, sparing the face (figures 1-6). The remainder of the exam was normal.
The patient had viral, bacterial and fungal cultures and stains performed on the lesions, and was empirically treated with intravenous acyclovir for the possibility of neonatal HSV infection. Bacterial and fungal stains were negative. The patient was monitored in the NICU and otherwise treated normally.
Dermatology obtained a biopsy of one of the lesions that showed numerous eosinophils within the superficial dermis and an area of hyperkeratosis.
Congenital candidiasis or neonatal candidiasis is an infection of the newborn with Candida albicans (figures 7-10), depending on whether the baby acquires the infection in utero or postnatally. Figure 11 is a smear of a lesion showing the budding yeast typical of Candida. Ophthalmologic exam and urine fungal cultures can be used to look for evidence of dissemination. When this condition is diagnosed in a newborn, most experts recommend treating the baby with amphotericin B. We have adopted the use of liposomal amphotericin B in almost all patients, which is associated with less toxicity. Additionally, one can give much larger doses (up to 5 mg/kg/day) allowing for potentially shorter course of therapy. Figures 12 and 13 show the same baby after therapy with amphotericin B.
Erythema toxicum is a papulopustular rash of newborns (figures 14 and 15). The lesions typically are on erythematous bases, but not always, and tend to appear by day 2 of age. They are usually located on the trunk, but can occur anywhere, but usually not the palms and soles. They tend to last about 5 days with new lesions appearing for up to 2 weeks of age. The underlying cause is unclear, but it is self-limiting and requires no treatment except reassurance. The Grams stain is negative as well as the culture, but the fluid usually contains some eosinophils, as in IP.
IP is an uncommon disease that causes a vesicular rash in neonates. This diagnosis should be considered in any female neonate who presents with a vesicular rash. However, it is also important to rule out the infectious causes of vesicular rashes in neonates, which can be life threatening.
Neonatal HSV infection does share some features with IP but with a careful history and physical exam, differentiation between the 2 entities should be possible. The differences found include maternal and family history, the pattern and age of onset of the rash, and clinical stability of the patient. The rash in HSV is typically vesicular and usually has its onset after day 4 of life. The infant with HSV usually has signs of clinical instability. In IP, there is typically a positive family history. The rash is noted to be in whorls following a dermatomal distribution and may be present from birth. Clinically, these patients are stable.
The diagnosis of HSV or IP does not rule out the other diagnosis; however, and completion of the work-up for the cause of the rash is necessary because these 2 illnesses can coexist in the same patient. As seen in our patient, the rash was noted within the first 2 days of life and dermatomal in distribution. She was clinically stable and there was a positive family history of IP that helped direct us to the correct diagnosis. Patients with IP deserve early diagnosis so that they can be followed for the development of any of the other medical problems related to the disease.
Acknowledgment: Thanks go to Charles Oltorf, MD, Neonatologist at Scott & White for his assistance with this case.
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