Visual Diagnosis: Unusual Skin Findings in a Premature Infant.

Abstract

1. Sneha Butala, MD* 2. Lauren Pronman, DO*,† 3. Michelle Baechtold, MD‡ 4. Timmie R. Sharma, MD‡ 5. Rebecca Fish, MD§ 6. Qin Yao, MD§ 1. *Department of Pediatrics and 2. §Division of Neonatology and Perinatal Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH 3. †Department of Genetics and Genomics and 4. ‡Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, OH A 24-year-old gravida 2 para 1 woman presents at 32 weeks’ gestation with vaginal bleeding concerning for placental abruption. The prenatal history is unclear because the mother obtained most of her prenatal care in Mexico. She precipitously gives birth to a female infant via breech vaginal delivery. On delivery, the infant is intubated and given 1 dose of surfactant due to respiratory failure. Apgar scores are 2 and 3 at 1 and 5 minutes, respectively. The birthweight is 1,900 g. A chest radiograph demonstrates diffuse severe alveolar opacity in bilateral lung fields consistent with severe respiratory distress syndrome. The infant is transported to a tertiary center and develops worsening hypoxia requiring 100% oxygen. The blood gas on admission reveals severe mixed respiratory and metabolic acidosis. The infant receives additional doses of surfactant and a prolonged period of respiratory support. The severity of the infant’s respiratory distress syndrome is disproportionate to the degree of prematurity. Pertinent physical examination findings include mottling of the skin with thick white scale. The scale is symmetrical, involving the scalp, shoulders, and extremities (Figs 1 and 2). External ear canals are not visible; they may be absent or occluded by the scale, which is also found around the nares. Thin erosions in rectangular shapes on her abdomen are noted where cardiac leads have been placed. Erosions are also found on the right side of the face near the endotracheal tube securement device and on the bilateral dorsum of feet. Auscultation of the lungs reveals coarse breath sounds and diffuse crackles bilaterally, without increased work of breathing, retractions, or nasal flaring. There is no collodion membrane, ectropion (outturning of the eyelids), or eclabium (outturning of the lips) present. Figure 1. Thick adherent scales and erosions on day 1. Figure 2. Thick adherent scales and erosions at 4 weeks. The complete blood …