Hot Seat Case #95: 22 day old with a rash
Posted on: May 30, 2017, by : Nadira Ramkhelawan
Nadira Ramkhelawan MD, INOVA Fairfax Children’s Hospital
with Pavan Zaveri MD, Children’s National Medical Center
The Case:
A 22 day old FT boy who presented with desquamating areas on his left groin, penis, fingers and left antecubital area. Parents reported 3 days PTA they noticed redness and peeling of skin on his right distal thumb and a blister in the left groin area. They attributed the groin lesion to the diaper rubbing against the skin, and the thumb lesion to thumb sucking. However, began to become worried as the areas were enlarging at home.
No herpetic family history. No recent medications. No new topical exposures.
ROS: No fevers, no vomiting, no diarrhea, feeding normally and gaining weight properly, no seizure like activity. No one else with similar rash.
PMH: Full term, unremarkable birth history.
PE: T 36.8 °C, HR 151, BP 74/46, RR47, SpO2 97 % on RA, Wt 3.37 kg
General: Well appearing, NAD
HEENT: NC/AT, AFOF, moist mucous membranes, oropharynx nonerythematous with no lesions.
CV: RRR no murmurs or rubs. Cap refill <3secs.
Pulm: Good air entry bilaterally, no wheezing or crackles. No retractions.
Abd: +BS, soft, NTND, no HSM
Neuro: Awake and alert,
Skin: Warm and dry. 2.5 cm desquamated area in left groin area. Right thumb and ring finger with erythema, desquamation and healing black scabs. Left pointer finger with developing erythema. Right antecubital area with 3mm blister unroofed.
Photo shown below:
** Disclaimer: this is not an actual picture of the patient, http://img.medscapestatic.com/pi/features/slideshow-slide/infect-skin/updated/fig7.jpg?resize=645:439 **
Questions for you:
ID is consulted. A full sepsis work up is performed, as well as surface swabs for HSV and bacterial culture.
CBC WBC: 8.26 (normal differential), H/H 12/36, plts: 274
UA negative for nitrites or leukocyte esterase, 6-10 WBC
CSF: 193 RBC’s, 5 WBC’s, 145 Protein, Glucose 43, CSF HSV pending
Chem 20 is within normal limits.
One More Question:
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Rashes and neonates- either benign or deadly, nothing in between.
And why is it that the names of the benign ones sound so terrible?
Here the issue is a desquamating rash. Most of these are not benign. Too young for bullous pemphigoid tho’ there are case reports in the literature.
Strep and Kawasaki desquamate, but not like this. The teaching pearl here would to microscopically differentiate one bad disease, from a less bad disease. Yes, a read-my-mind statement. Time to see some fellows chime in here……
This looks like a classic case of Ritter’s disease, a.k.a., Staphylococcal Scalded Skin Syndrome (SSSS), which incidentally is also known as Pemphigus neonatorum — leapfrogging off Maybelle’s comment above. Although I’d admit for IV antibiotics, I’m not sure this child needs a full sepsis evaluation (as requested by ID), as we are not looking for a source of this child’s fever — this child has no fever and no concern for sepsis. We know the diagnosis by looking at the rash! An LP is an invasive procedure — and meningitis would not present with sloughing skin!
From the description, i would agree this is SSSS. desquamating bullous impetigo with toxin-mediated component is essentially SSSS since there are lesions in remote areas from others (thumb and abdomen). This differentiates it from a localized disease. Without fevers or hypothermia or signs of instability, not much reason to do a septic workup here. But patient does require treatment. Even though i’m generally in favor of discharging everyone, i’d probably admit this kid on IV antibiotics for a day and consult nobody. Just because it’s a high risk group and any spread of desquamating rash will really weaken skin barrier and defense and prone to superinfection, temperature regulation, and ability to fight this one.
agree with Dewesh 100%. what are the odds of that?!?!?!?!?!.
isn’t this what ETU was made for?
what the heck is a chem20 btw? sounds awesome.
Gosh, Dewesh and Dave, I was being cryptic because I hoped to hear what the fellows thought… hint hint… Nikolsky sign.
Yes, SSSS is the most likely. Also on the neonatal differential is EB and congenital syphillis can sometimes present with sloughing (and snuffles). Not this baby, but the last bad sloughing rash is TEN.
We don’t have an obs unit so this baby is staying. Handling: contact precautions and gentle skin care.
Rashes and neonates – I think those folks above have said enough….
Observation – now a much more fun topic to postulate on….While OBS units are meant for up to 23 hrs, when your ED has insufficient bedspaces for the ED patients, limiting observation to 4-6 hrs may be in our better interest. This whole concept has become much more complicated with the observation vs. inpatient designation as well that our hospitals and insurers are trying to navigate through. Our comfort and ability to observe patients in the ED has definitely evolved as our inpatient friends have also evolved their practice.
In my own f/u and reflection, I note many BRUE and asthma patients being discharged <23 hrs from the inpatient unit….so are we doing them a service by sending them upstairs or should we watch everyone longer for possible discharge. There is no right answer to this, as there are many "market" forces that affect the decisions to have ED-based obs vs. inpatient-based obs. Amongst those include: payers' willingness to pay whom, hospital occupancy, dedicated service lines (hospitalists, etc.) what the hospital can get the most financially out of, etc.
More to think about then advise to the fellows….Good luck,
I like the plan for admit on IV antibiotics for presumed SSSS, watch for temp instability and fever. Trying to imagine how to navigate the inevitable request for a septic workup from the floor team – discuss why we think un-necessary of course, but then if insistent – comply? decline and suggest they do it if that worried? just watch in the ED instead?
Agree with Caleb. I find it difficult to imagine a scenario where this child gets admitted to a pediatric floor without a full septic workup. Maybe I can hypothesize a scenario where I talk to a floor attending who is able to come down and see the child and I can convince him/her of my thought process, but that seems unlikely. I am not saying this child needs a full septic work up, I just think in reality (whether we like it or not) he/she likely gets one. Curious what the response from the pediatric floor team at INOVA was…
An approach that may be more comfortable all around is to treat with topical antibiotics, since this looks like bullous impetigo, or localized SSSS– with flaccid bullae that shear easily. Causative organisms are Staph aureus and GAS. MRSA usually causes more of the suppurative infections such as abscesses, and less often cause the toxin mediated problems. Given that the neonate is well appearing and in hospital, a course of topical antibiotic for MSSA and GAS could be chosen and hold off on iv antibiotics.