Vesicopustular Eruption in a Neonate

At 38 weeks gestation, a 3,210-g male infant was born via normal spontaneous vaginal delivery to a healthy 23-year-old white mother, G4P3, with no prenatal or delivery complications. Two days after delivery, the baby was transferred to the neonatal intensive care unit (NICU) for respiratory distress, leukocytosis, severe thrombocytopenia, and elevated hematocrit. The baby was afebrile and found on physical examination to have slight dysmorphic features, including low-set ears and hypertelorism; he also had splenomegaly. Further workup was significant for renal ultrasound with left pelviectasis; for X-ray of the limbs showing features of trident hand; and for brain ultrasound showing questionable hypoplasia of the corpus collosum. Echocardiogram study revealed a fenestrated atrial septal defect, bicuspid aortic valve, and septal hypertrophy. Chest X-ray was normal. Laboratory workup revealed a high white blood count of 35.8 (normal range, 9 K/uL to 30 K/uL); hemoglobin 20 (10 g/dL to 18 g/dL); hematocrit 60 (31% to 55%); and low platelet level of 24 (150 K/uL to 500 K/uL). On the fifth day of life, erythematous vesicopustules were noted on the baby’s cheeks. Over the course of a week, the baby developed more erythematous vesicles on bilateral dorsal hands, feet, extremities, and few within scalp, with sparing of palms and soles (Figures 1, 2, and 3, see pages 186, 187). Dermatology was consulted on the 14th day of life for consultation of the skin lesions. Cultures sent from pustules for viral, fungal, and bacterial cultures were all negative. Titers for cytomegalovirus (CMV) and toxoplasmosis were negative. A smear was performed from a vesicle on the right dorsal foot and prepared with Wright’s stain. The smear results (Figure 4, see page 187) showed numerous atypical myeloblasts and mixed infiltrate of neutrophils and few eosinophils. Supportive skin care regimen was recommended, including mupirocin ointment to any eroded lesions. The baby was transferred to another medical center for further evaluation. Kaleroy Papantoniou, MD, is a Resident in Dermatology, PGY4, Department of Dermatology, SUNY Downstate Medical Center. Maria L. Sulis, MD, is Pediatric Hematologist-Oncologist; and Assistant Professor of Pediatrics Columbia Presbyterian, New York, NY. Sharon Glick, MD, is a Pediatric Dermatologist; and Director of Dermatology, SUNY Downstate Medical Center, Brooklyn, NY. Drs. Papantoniou, Sulis, and Glick have disclosed no relevant financial relationships. Address correspondence to: Sharon Glick via email: Sharon.glick2009@gmail.com. doi: 10.3928/00904481-20120426-05