Hot Seat Case # 107: 6 month old M with recalcitrant rash
Posted on: February 18, 2018, by : Amie Cahill
Amie Cahill, MD Children’s National Medical Center
with Karie Button, MD Children’s National Medical Center
6 mo healthy male born term without complications, UTD on immunizations, presented to ED with worsening rash on scalp and diaper region for the last month. Parents tried nystatin and then OTC hydrocortisone without relief. The patient was seen multiple times for this complaint by both his PMD and the ED. Finally, patient was referred to the ED, when rash appeared worsened to his PMD. No pustules/vesicles/crusting, no fevers, no change in PO intake or UOP, no change in alertness or activity level.
PMHx: Born FT NSVD, no complications during pregnancy. No previous hospitalizations. No medications other than ketoconazole topical cream. NKDA.
FHx: none
ROS: No fever, no irritability, no decreased alertness. SKIN: scaly rash on scalp and face, rash on neck/trunk/axilla, large red rash in diaper area. HEENT: no red eyes, no nasal dc, no oral lesions. RESPIRATORY: no cough, no wheeze/stridor/apnea/cyanosis, no rapid breathing. GI: no V/D, no abd distention. GU: no hematuria or dark urine. MSK: no joint redness/swelling, no disuse of any limbs; HEME: no petechial/purpura, no bruising.
Vital signs: T 37.4 HR 153 RR 30 O2 100%
General: WNWD, well hydrated, alert, smiling/interactive/playful infant
HEENT: NCAT, entire scalp covered in thick, yellow, scaling plaques and erythematous patches extending to neck and face to involve forehead, eyebrows, ears (pre-&post-auricular and pinna). PERRL, clear conjunctiva, nares patent, MMM, OP clear with no mucosal lesions.
CV: S1S2 RRR, no m/g/r, 2+ pulses, CR <2sec
LUNGS: CTAB, no w/r/r, no increased WOB
ABD: Soft, Non-tender, non-distended, no HSM
GU: brightly erythematous confluent plaques involving entire diaper region anteriorly and posteriorly with intertriginous involvement but largely sparing scrotum extending to mons pubis, medial thighs, and lumbar region of back. +overlying shininess and thin scaling of skin. +a few satellite patches extending to umbilicus, clear demarcation. No vesicles/pustules/ulcerations. No tenderness.
MSK: MAEW and symmetrically, no point TTP, no apparent pain with ROM
SKIN: in addition to pertinent findings described above in HEENT and GU- erythematous patches (some moist, some scaly) in neck folds, axilla, and smaller scattered patches on trunk; no petechia/purpura/ecchymosis
LN: no cervical/supraclavicular/axillar/inguinal/popliteal LAD
NEURO: alert, active, CNs appear intact, symmetrical movements
** Disclaimer: this is not an actual picture of the patient, images obtained from MEDSCAPE
https://reference.medscape.com/slideshow/skin-conditions-infancy-6000980#10**
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
Excellent case – we see so many rashes! I think what concerns me is how widespread it is and unresponsive to other treatments. Doesn’t appear fungal on first glance. My biggest concern based on the story is Langerhan’s Cell Histiocytosis (hence why I said consider consulting oncology). I’ve seen zinc deficiency have a similarly terrible rash, though facial rash is usually cheeks/perioral and not on the back of the head like this. I think given the severity and how long it’s been going on, I would get most of the labs offered and likely admit unless I had a clear diagnosis and plan from dermatology. This patient has been trying outpatient for a month with worsening, so I’d need to be convinced of a solid plan to send him home.
Such an interesting case! The prolonged nature of it without associated systemic signs and in an otherwise well appearing, afebrile, well hydrated infant makes ddx tricky (infectious and allergic lower on list?). The presence of rash on the scalp and diaper area without associated vesicles, pustules or petechiae and w/out systemic signs makes seborrheic dermatitis a possibility (would be an impressive case of it I think!), although agree w/Isbey that LCH skin findings can be mistaken for prolonged seb dermatitis & can also have diaper rash that looks candidal in nature – would not want to miss this & thus would strongly consider baseline lab evaluation (all that were listed) and Derm consult as starting point in the ED.
Agree with above. How much time do I have in the ER to be a diagnostician vs r/o emergency and follow up with key specialist is key! I absolutely want to r/o any “big” critical diagnoses like LCH. However, Derm would be a helpful consult to help with one of the key decision making points in the ED — can this be managed as an outpatient or not? This kid is thriving — afebrile, well appearing, hopefully good percentiles for body weight so my sick vs not sick radar is swinging to the latter. I presume the detailed family or social history didn’t reveal any red flags about atopy or new products being used on this baby (like any homeopathic treatments that might have ingedients they could be sensitive to?) I’m not sure what the reason to admit with derm consult would be if this kid has normal labs. This does not scream of superinfection to me. I would think this could be worked up as an outpatient and does not require a hospital bed. I would tie in the PMD and connect with Derm.