Case 1: A ‘rash’-ional approach to recalcitrant diaper dermatitis

Abstract

A previously healthy eight-week-old male infant was transferred from a peripheral hospital after presenting with acute lethargy. During a visit with his father for the weekend, the child apparently awoke with an intense episode of loud and unusual crying lasting 20 min, followed by a decreased level of consciousness with no associated abnormal movements or cyanosis. He had been well just before the event, with no fever, vomiting, diarrhea or rash. His parents brought him to their community hospital, where he was noted to be lethargic and difficult to arouse, with pale, mottled skin and a rectal temperature of 35oC. Intravenous ceftriaxone, vancomycin and acyclovir were immediately started for possible sepsis before blood and cerebrospinal fluid cultures were drawn. The infant was otherwise healthy following an uncomplicated prenatal course and term vaginal delivery with a birthweight of 3.6 kg. The mother and father, aged 18 and 20 years, respectively, were healthy and had no other children. After transfer from the peripheral site approximately 8 h after the initial episode, his level of consciousness was appropriate and he was interacting normally. Vital signs were stable, with a temperature of 37.8oC, and his weight was 5.5 kg. The anterior fontanelle was full, but not tense, and the neurological examination was normal. His retinas were not examined. The rest of the physical examination was unremarkable. A cranial ultrasound performed in the periphery was reportedly normal. A full septic workup was performed following transfer and initiation of antimicrobials. Complete blood count and urine dip were within normal limits. Cerebrospinal fluid appeared bloody, with negative Gram stain, 200×106/L leukocytes (48% neutrophils), 49,800×106/L erythrocytes, 1.13 g/L protein and 2.6 mmol/L glucose (62% of blood glucose). Coagulation studies were normal, and serum glucose was 4.2 mmol/L. Electrocardiogram, toxicology screen, metabolic amino acid screen and abdominal ultrasound were all normal. Further testing revealed the diagnosis.