with Jennifer Anders, Johns Hopkins, on the Hot Seat
Case edited by Emily Willner, Children's National
19 day old full term female, with history of a 10 day NICU stay for E.Coli sepsis, presents with painless pustules on the palm of the right hand. They began 2 days ago as red spots, which then evolved into pustules. Today some of the lesions are “drying up”.
ROS is otherwise negative: no fever, breast feeding well, normal voids and bowel movements, no vomiting, normal activity. She was being treated for oral thrush and a diaper rash with nystatin for the past 6 days. No sick or similarly affected contacts at home, and no family members with cold sores.
Birth hx: 38 week, Vaginal delivery. GBS neg. No maternal history of HSV. Couldn’t maintain temperature after birth, so transferred to NICU where a sepsis eval revealed E. Coli bacteremia. Baby has done well since discharge 9 days ago.
Physical Exam:
Vitals: T 37.5F rectal, P:140, R: 44, pulse ox 97%
Well appearing, appropriately active baby. OP with thick white adherent plaques on the buccal mucosa. Rash on palmar surface and digits of right hand: Numerous 2-3mm pustules on erythematous base, some discrete, mostly coalescent, in a linear distribution on the distal palmar surface, with clusters at the bases of the fingers, webspaces and along the side of the fingers especially on the 4th finger [see photo]. Thigh: Erythematous papules on posterior thighs bilaterally. No satellite lesions seen.
Cardiopulmonary exam is normal with clear lungs, normal work of breathing, and regular rhythm with no cardiac murmur. Abdomen is soft and nontender without organomegaly.
Tone and newborn reflexes are normal.
.jpg)
Questions for You (click on "Vote" to see what others said)
You have contacted the PCP and can assure close follow up. The baby remains afebrile and vigorous, and feeds well while in ED. The gram stain of the pustule fluid returns showing: no bacteria, rare WBC/RBC, mod epi. If you chose other testing, assume results are also reassuring (except HSV, which will not be back for 24-48 hrs).
How would you approach this case? Please share your opinions by clicking on "comments" here or below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.
Click here to read the Hot Seat Response and Denouement for this case
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
Why am I always the first person to respond to these? My general approach in the ED is: shotgun diagnosis, what else could it be, does the patient have risk factors to make me worry more.
ReplyDeleteSHOTGUN DX: cutaneous candidiasis
What else could this be: confined to the hands/feet is reassuring because it really limits the differential to some form of acropustulosis of infancy. older infants get dyshidrotic eczema. impetigo/SSSS usually starts in umbilicus or diaper and there are no systemic symptoms here to indicate toxin-mediated spread. herpes? this is always a tricky one because if you suspect it in this age group, it really buys the whole shebang workup. but I would argue that these are really pustular and not vesicular so I wouldn't necessarily go down that route. There are probably other things to think about so if I was seeing the patient I might do a google search, but the lack of true systemic symptoms is reassuring.
RISK FACTORS: the patient had e.coli bacteremia about 2 weeks ago. i'm assuming received 10d of antibiotics and then went home. I thought we did longer of courses of antibiotics for that, so i'm assuming CSF was negative and this was thought to be maternal transmission? I would check the newborn screen for galactosemia to be safe. Recent antibiotic use is a setup for candida infections, but a candida infection in the setting of recent illness also makes me concerned about an underlying immune disease. and systemic candidiasis can be fatal.
What to do: I would draw a CBC and blood cx. blood cx given recent history, CBC to make sure the child isn't thrombocytopenic (a herald for systemic fungal disease). that CBC might get me in trouble though if I can't evaluate for trend on the white count from the NICU. I would swab the hand for bacterial culture, fungal culture, and send an HSV PCR. I would contact the pediatrician and assure f/u in the AM. and I would initiate treatment for topical (and oral) candidiasis.
I would be cautious in only considering HSV in vesicular neonatal rashes - HSV can appear pustular. The lesions are described as having an erythematous base, are coalescing and some appear to be drying. Also there are two rashes in different stages(palm and thighs), all concerning for HSV. Classically isolated SEM (skin, eyes, mucous membranes) HSV presents at 10-14 days, so this child is a little old but still high risk. I would do it all: CBC, CMP(elevated transaminases to check for disseminated HSV), LP, HSV swabs, etc. and start the baby on IV acyclovir, abx and admit until the HSV PCR is back. The other diagnosis to consider for neonatal pustular lesions is staph pustulosis. These lesions, in my limited experience are difficult to distinguish from HSV but are more commonly found in the diaper area or lower abdominal wall, do not coalesce, are usually very small and similar to this infant are otherwise asymptomatic (no fever, etc). The negative gram stain goes against staph pustulosis (doesn’t rule it out) and makes me worry more about HSV. -- Shilpa
ReplyDeleteI would also go for the whole septic work up, admit, acyclovir and ATBx. I agree the child looks very well, but we also know that that's not enough in this age group. But mostly, the candidiasis could be secondary to the antibiotics, but what if the candidiasis, this rash, the E coli sepsis were all from an immunodeficiency which would also put this baby at high risk for HSV which could start cutaneously and quickly go systemic.
ReplyDeleteI have a feeling I'm wrong and this case is surely much simpler, but seeing this child in the ED with that history and exam, I will do the whole workup.
Rasha
Hi from California. I hope those hands were washed after taking that picture...
ReplyDeleteThe formation looks herpetic to me, with possibly impetiginous yellowness off the top of the photo where it gets blurry. Clear vesicles with some that join up; haven't seen many other lesions do those clustering in linear fashion except perhaps poison ivy or local reaction.
I hesitate to do an LP but would be worried if a 19d F already had a viral infection, a bacterial infection, and a fungal infection not responsive or even getting better on nystatin, and would at minimum admit for IV acyclovir; the floor can LP and do abx if needed.
The adult hands are the parent's hands:)
DeleteWith any baby less than 28 days, presenting with either fever or signs of a focal infection, I am going to be pretty concerned about systemic infection. I am especially concerned given this baby’s history of perinatal sepsis. So despite the reassuring lack of fever, given the pustular and erythematous appearance of the hand I would still proceed with a full septis workup including HSV evaluation. Since risk stratification by lab results or clinical appearance is poor in this age group, I would also admit with empiric treatment for both bacteremia and HSV.
ReplyDeleteSo that covers high risk, but I don’t think HSV is the highest likelihood diagnosis. I’ve organized my thinking around three main areas to narrow the differential. This is a very young infant, the rash has a distinct distribution on the hand, and the baby has prior medical history and concurrent infection with thrush.
Age. HSV must be considered in a newborn with a papulovesicular rash. This rash is more confluent than I expect from neonatal HSV, and more pustular than vesicular. The tight clustering and pustules look more like herpetic whitlow, which I have never seen at this early age. Could an adult shedding oral HSV been kissing the baby’s hand? I would ask more about caregivers’ cold sore history.
Could this be a neonatal pustulosis syndrome (transient neonatal pustular melanosis or acropustulosis of infancy)? TNPM should be present at birth, resolving over the first week of life, so that doesn’t fit for this baby. Acropustulosis of infancy is often on the palms and presents in the first weeks of life, so the timing is good. In both those cases, the lesions should be filled with neutrophils, which was negative for this patient.
Erythema toxicum typically shows up earlier in the newborn period than this (first week of life), should not cluster like this, not show up on the palms and the photos don’t look right for e tox. Those lesions should have smaller rounder papules or vesicles on pink base.
Distribution of rash. The description of location in the hand is intriguing. Since there was no picture of the scattered papules on the thighs, I disregarded them, which could leave me vulnerable to missing something!
I like the possibility of acropustulosis given the location and appearance. The description of vesicles/pustules in the webspaces and sides of fingers makes me curious about scabies – although that classic distribution in bigger people is not usually the distribution in infants. But location on the palms is common in babies.
I have seen several newborns with impetigo/staph with pustules that look just like this. Could this baby be sucking her fingers and creating skin break down? Was this hand used for her IV in the NICU and became secondarily infected? Like the pustulosis syndromes, I would expect more neutrophils in the smear of the lesion if this was staph infection.
Past history/associated signs and symptoms. With the thrush and diaper rash described, could this be some sort of candidal skin infection? Candida on a dry skin surface with thick epidermis (aka the palm) is unusual, but baby might be sucking her fingers.
Other questions that I pondered but don’t have good answers for include: Could this be soft tissue seeding with E. coli related to the prior sepsis? I don’t think so. Could this be something picked up in the NICU? I don’t even know what to suspect beyond staph. My blood culture and culture of lesions should cover both those possibilities. Could this be allergic or post traumatic response to the IV access or tape used in the previous hospitalization? If so, there is nothing to do but supportive care and if baby has a tape allergy I will probably see new evidence after this episode of care.
So in conclusion, I am going to do a full sepsis work up and admit on antibiotics and acyclovir. I will have a dermatologist consult while the baby is an inpatient.
My ranked differential diagnosis for the rash itself is:
1. Staph infection
2. Acropustulosis of infancy
3. HSV
4. Allergic reaction (to tape used for IV?)
5. Candida infection
I was on when this kid came in and heard about the case so won't provide any spoilers. After I found out about the diagnosis, my takeaway (aha!) learning point was: "Common things are common." When you see something that is unusual, go back to "most common" diagnoses and consider those first. If you saw on the tracking board "3 week old with new rash," what would be #1 in your mind for all-comers?
ReplyDeleteI like your reassurance Paul about common things being common so this is likely acropustulosis of infancy. BUT .. I agree with all above in terms of a septic work up given this patient's history. One of the main lessons I took out of my residency is "Do NOT trust babies" - they can look well one minute and fall off the cliff in the next - particularly if they have a suspect neonatal history as this baby does. But as my years of practice increase, it is helpful to have more and more experience with those "normal rashes" that mimic ugly stuff like HSV. That being said, I usually refer to the Healthy Children website from the AAP to provide parents with their synopsis of typical rashes in a healthy newborn. It is very informative and can be found at: http://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Your-Newborns-Skin-Birthmarks-and-Rashes.aspx. I have made it into a routine handout for patients
ReplyDelete(PS I am likely going down the septic work up with LP and admit route -- I might send that pic to the NICU docs as well to get their insights).
Looking forward to the denouement!
Joelle
PS - I know I am not THAT old, but I liked Histology in medical school and liked having a microscope in the ED in residency and reading vag swabs so I can have a dx right away. This is one of those times I wish we had a microscope as well and could do a gram stain of the lesion or at least get a quick path read from a swab.
ReplyDelete