Visual Diagnosis

Abstract

1. Lopa Shah, MD* 2. Gita Balakumar, MD* 1. *University of Nevada School of Medicine, Las Vegas, Nev A 3-week-old girl presents to the clinic for a persistent rash that has been present since birth. Following an uncomplicated term gestation, the infant was born by cesarian section due to prolonged dilation and failure to progress. She weighed 3.2 kg. A rash was noted at birth on her left lower extremity, and her parents were reassured that the rash would resolve. However, the rash now extends over both lower extremities. The mother has not applied any creams, lotions, or topical medications to the infant’s skin. The family history is noncontributory; there is no history of nervous system or skin disorders. The infant is well-appearing, comfortable, and afebrile. She weighs 3.54 kg (25th percentile). Skin examination reveals red, hyperpigmented streaks and plaques on the upper part of her lower extremities (Fig. 1), with occasional vesicles distributed linearly (Fig. 2). An accessory nipple is noted on the right chest wall. The infant is active, there is no evidence of scratching, and her muscle strength and tone are normal for age. The remaining physical findings are normal. Figure 1. Red, hyperpigmented streaks and plaques on left lower extremity. Figure 2. Vesicles on left lower extremity. A complete blood count demonstrates: hemoglobin, 12.5 g/L (125 g/L); white blood cell count, 46.3×103/mcL (46.3×109/L) with 14% neutrophils, 2% bands, 33% lymphocytes, 44% eosinophils, and 1% myelocytes; and platelet count, 560.0×103/mcL (560.0×109/L). Peripheral blood smear reveals a slight normochromic, normocytic anemia with erythropenia, normal red cells with a few teardrop cells, moderately increased number of platelets, and a mild-to-moderate increase of white blood cells with relative and absolute eosinophilia. A clinical diagnosis is made. The presence of vesicular and hyperpigmented linear skin lesions since birth, their distribution over lines of Blaschko, and the laboratory finding of …