Nadira Ramkhelawan MD, INOVA Fairfax Children’s Hospital

The Case:
A 22 day old who presented with an afebrile desquamating rash on his groin, fingers, and left forearm.

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Discussion:
The poll results for this case indicated relative agreement amongst respondents, with most opting for the full sepsis evaluation. Interestingly enough, this was in light of making disposition decisions smoother and with less pushback from the admitting team. Much of the group decided that a “full sepsis workup” should be reserved for febrile infants in which a serious bacterial illness is presumed, however, this child was afebrile with a relatively cutaneous localizing disease process.

The general consensus for the team present was that this child does need to be admitted for antibiotics +/- antivirals with the caveat that this admission would most likely be for 24 hours or less. Dr. Mathison validates this decision through his concerns of further skin break down resulting in potential thermoregulatory instability, dehydration, and/or super-infection.

Dr. Chapman reminded us that in localized impetigo, topical antibiotics is a viable option. However, in this child with lesions disseminated on his finger, groin, and lower abdomen, one would presume this could result from self-inoculation or potential dissemination which would prompt systemic antimicrobials.

Denouement:
Infectious Disease were consulted in the ED. Based on the desquamation, highest on their differential was SSSS, but the acral distribution is not typically seen in this and thus could not rule out HSV.  A full sepsis evaluation was performed, which was unremarkable. A wound culture was obtained from the area of desquamation in the left groin area and HSV swab was taken from eyes, umbilicus and rectal area of which were negative. The patient was begun on cefepime to cover for MSSA, clindamycin for toxin mediated injury and acyclovir for HSV coverage and admitted.

Dermatology was also consulted, as the differential included epidermolysis bullosa or neonatal pemphigoid. However, shortly thereafter, the wound culture grew MSSA suggesting SSSS. The patient continued to do well clinically without new lesions.  Cefepime and clindamycin were subsequently changed for cephalexin when susceptibilities were resulted. 

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