Index of Suspicion in the Nursery

Abstract

A 5-day-old girl is brought to the emergency department for evaluation of a new rash. The mother describes multiple small red lesions that started on the chest on the second day after birth and are progressing to become fluid-filled bumps involving the face, trunk, arms, and genitalia. The infant is eating and sleeping well, has adequate stool and urine output and has no fever or irritability. She was born at 38 weeks’ gestation via a spontaneous vaginal delivery to a mother with a previously treated chlamydia infection during early pregnancy. There are no other prenatal or perinatal complications. There is no documented rash in the newborn’s brief nursery records and no family history of any dermatologic conditions. Her initial physical examination reveals a well-appearing, afebrile infant with vital signs and weight within normal limits. A complete physical examination is within normal limits except for her skin examination. There are multiple discrete 1- to 3-mm pinpoint amber vesicles without underlying erythema present over the trunk, face, and genitalia and a 1-cm isolated bulla on her chest. The vesicles are nontender and do not rupture easily when touched. Many of the amber-colored vesicles on the face have eroded, leaving honey-colored crusts surrounding them (Fig 1). Additionally, there are several erythematous 1-cm round plaques on her trunk and upper extremities. Figure 1. Initial presentation of honey-colored small vesicles and superficial erosions with honey-colored crusts. Due to the presence of bullae and honey-colored crusting on many of the lesions, the patient is diagnosed with bullous impetigo and is discharged from the emergency department on a 10-day course of …