Index of Suspicion in the Nursery

Abstract

A 3-week-old white male infant presents to the emergency department for evaluation of extensive facial dermatitis. He was born by vaginal delivery at 39 weeks’ gestation to a 27-year-old primigravid woman who had an uncomplicated pregnancy. The maternal prenatal screening results were negative. Apgar scores were 9 at 1, 5, and 10 minutes, and no blisters were noted either at birth or in the immediate perinatal period. His birthweight was 3.6 kg. He is being fed standard cow milk formula and has good weight gain. Three days ago, he developed perioral redness, which has progressed to involve the entire face. He had been fussy since the onset of the rash but has remained active, has been feeding well, and has had normal urination and stooling. He has had no fevers or other symptoms and is not taking any medications. There is no family history of blistering or other dermatologic disease, and the infant has had no sick contacts. On physical examination, the infant's weight, height, and head circumference are at the 50th percentile. His temperature is 101.3°F (38.5°C), pulse is 120 beats/min, respiratory rate is 30 breaths/min, and blood pressure is 90/40 mm Hg. Skin examination reveals diffuse erythema, desquamation, fissuring and honey crusting in the perioral and cheek areas (Fig. 1). Fine desquamation also is apparent in the flexural areas, namely, the axillae (Fig. 2), groin, and gluteal cleft (Fig. 3). He has several intact flaccid bullae on the hands (Fig. 4). He has conjunctival mucus discharge without conjunctival injection but no intraoral lesions. His cardiac, respiratory, abdominal, genitourinary, and neurologic examination results are normal. Figure 1. Fissuring and honey crusting in the perioral and cheek areas. Figure 2. Desquamation in the axilla. Figure 3. Desquamation in the gluteal cleft. Figure 4. Erythema and flaccid bullae on the hands and fingers. Results of laboratory tests include hemoglobin …