Sarah E. Stewart, MD, a Jody L. Lin, MD, b Jennifer L. Everhart, MD,b Trung H. Pham, MD, PhD, c Well-AppearingAnn L. Marqueling, MD, d, e Kerri E. Rieger, MD, PhD, d,Newborn f Sarah L. Hilgenberg, MDb With a Vesiculobullous Rash at Birth abstract A term, appropriate-for-gestational-age, male infant born via normal spontaneous vaginal delivery presented at birth with a full-body erythematous, vesiculobullous rash. He was well-appearing with normal vital signs and hypoglycemia that quickly resolved. His father had a history Divisions of aGeneral Pediatrics, bPediatric Hospital c of herpes labialis. His mother had an episode of herpes zoster during Medicine, and Pediatric Infectious Diseases, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, pregnancy and a prolonged rupture of membranes that was adequately Palo Alto, California; and Departments of dDermatology, e f treated. The patient underwent a sepsis workup, including 2‍ attempted Pediatrics, and Pathology, School of Medicine, Stanford University, Stanford, California but unsuccessful lumbar punctures, and was started on broad-spectrum antibiotics and acyclovir, given concerns about bacterial or viral infection. Dr Stewart contributed to the conception and design of the case presentation, drafted the The rash evolved over the course of several days. Subsequent workup, with initial manuscript, and reviewed and revised the particular attention to his history and presentation, led to his diagnosis. manuscript; Drs Lin and Everhart contributed to the conception and design of the case presentation and CASE HISTORY WITH SUBSPECIALTY reviewed and revised the manuscript; Drs Pham, Marqueling, and Reiger drafted their sections of INPUT ’ tests were negative for infection, the initial manuscript and reviewed and revised Dr Sarah Stewart (Pediatrics, First- the patient s mother received 3 the manuscript; Dr Hilgenberg contributed to the Year Resident) conception and design of the case presentation, dosesStreptococcus of clindamycin because of a drafted portions of the initial manuscript, and history of previous neonatal group ’ reviewed and revised the manuscript; and B (‍GBS) infection. The all authors approved the final manuscript as ’ The patient was a term, appropriate- patient s father had a history of herpes submitted. for-gestational-age, male infant born labialis. The patient s mother denied DOI: https:// doi. org/ 10. 1542/ peds. 2017- 0236 via normal spontaneous vaginal any history of herpes labialis or herpes Accepted for publication Jul 17, 2017 delivery who presented at birth with genitalis. ’ Address correspondence to Sarah E. Stewart, a full-body rash. The rash appeared MD, Division of General Pediatrics, Department The patient s initial laboratory results as diffuse discrete erythematous µ of Pediatrics, Lucile Packard Children’s Hospital, at 2‍ hours of life included a white 725 Welch Rd, Mail Code 5906, Palo Alto, CA 94304. papules and plaques with occasional – µ blood cell count of 2‍4.4 K/ L (‍normal: E-mail: [email protected] overlying fluid-filled vesicles and – 7.5 30.0 K/ L) with 74% neutrophils PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, bullae, most prominent on the face and – (‍normal: 32‍.0% 68.0%), 2‍0% 1098-4275). scalp but sparing mucous membranes, – lymphocytes (‍normal: 2‍4.0% 36.0%), Copyright 2018 by the American Academy of palms, and soles (‍Figs 1 and 2‍). He – © 4% monocytes (‍normal: 0.0% 0.9%), Pediatrics was well-appearing with normal vital – signs, Apgar scores of 8 and 9, a birth 1% eosinophils (‍normal: 0.0% 2‍.0%), FINANCIAL DISCLOSURE: Dr Lin received support weight of 3768 g, and an examination and 0% basophils (‍normal: 0.0% from the KL2 Mentored Career Development Award ’ – with results that were otherwise 1.0%); a C-reactive protein (‍CRP) level of the Stanford Clinical and Translational Science Award to Spectrum (NIH KL2 TR 001083, UL1 TR of 0.03 mg/dL (‍normal: 0.00 0.99 normal. His mother s pregnancy was – 001085) and the Clinical Excellence Research remarkable for presumed herpes mg/dL); a blood glucose level of 32‍ Center; the other authors have indicated they have mg/dL (‍normal: 45 110 mg/dL); an no financial relationships relevant to this article to zoster at 31 weeks that resolved – with valacyclovir. She had a history aspartate aminotransferase level of disclose. 68 IU/L (‍normal: 15 41 IU/L); an FUNDING: No external funding. of primary varicella-zoster at 2‍ years – alanine transaminase level of 8 IU/L of age and 2‍ episodes of herpes – zoster before this pregnancy. Labor (‍normal: 11 63 IU/L); a total bilirubin To cite: Stewart SE, Lin JL, Everhart JL, et al. Well- level of 3.1 mg/dL (‍normal: 2‍.0 6.0 Appearing Newborn With a Vesiculobullous Rash and delivery were complicated by a – prolonged rupture of membranes (‍2‍0 mg/dL); and an alkaline phosphatase at Birth. Pediatrics. 2018;141(3):e20170236 hours) and meconium-stained fluid. level of 110 IU/L (‍normal: 30 300 Though maternal prenatal laboratory IU/L). The remaining results of the Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 141, number 3, March 2018:e20170236 DIAGNOSTIC DILEMMAS FIGURE 1 Patient on first day of life. Coalescing erythematous vesicles are seen on the face, and dull gray and erythematous patches and plaques are seen on the body and extremities. The mucous membranes, hands, and the soles of the feet are spared. complete blood cell (‍CBC) count and comprehensive metabolic panel were unremarkable. Dr Hilgenberg, as a pediatric hospitalist assuming care of this infant after birth, what is your Drdifferential Hilgenberg diagnosis? (Pediatric Hospitalist) FIGURE 2 A, Lesions on the first day of life. B, New lesions on fingers on the fourth day of life. C, New lesions on ’ cheeks on the fourth day of life. D, Lesions on the fifth day of life. The forehead vesicles became less raised and less erythematous. A few new lesions appeared on the scalp. This infant s presentation is most “ ” concerning for one of the following: (‍1) a congenital TORCH infection, which is an infection caused by hepatosplenomegaly, intracranial cerebrospinal fluid pleocytosis, toxoplasmosis, other pathogens calcifications, and rash, as well as or elevated cerebrospinal fluid (‍varicella-zoster virus [VZV], syphilis, laboratory abnormalities. Despite protein. The incidence of congenital enteroviruses, or parvovirus B19), these common features, some clinical toxoplasmosis in the United rubella, cytomegalovirus, or herpes 1 ’ manifestations are more suggestive States is 1 4in 1000 to 1 in 10 000 simplex virus (‍HSV) ; (‍2‍) bacterial of particular infections in the newborns. sepsis, given the mother s previous neonate. neonatal GBS infection with her 2‍ For instance, congenital Congenital syphilis is characterized last pregnancy ; and (‍3) a primary toxoplasmosis has 4 subtypes: as either early, presenting before dermatologic condition such as subclinical, severe neonatal disease, 2‍ years of age but typically within Drepidermolysis Stewart bullosa (‍EB). mild or severe disease in the first the first 5 weeks of life, or late, few months of life, and sequelae presenting after 2‍ years of age. or relapse of an undiagnosed, Differentiating findings among How and when do TORCH infections typically ocular, infection later infants with early congenital typically present? What, if any, are in childhood. The minority of syphilis include nasal discharge, their dermatologic manifestations, ’ patients who are symptomatic maculopapular rash (‍particularly on given that skin lesions are our at birth may present with the the palms, soles, and diaper area), Drpatient Hilgenbergs only sign of illness? classic triad of chorioretinitis, generalized lymphadenopathy, and hydrocephalus, and intracranial skeletal abnormalities. Patients with calcifications. Dermatologic late congenital syphilis present with Interestingly, the majority of live- features include a maculopapular,1, 3 physical anomalies, such as teeth born infants with TORCH infections3 petechial, or purpuric rash. or bony abnormalities, but rarely are asymptomatic at birth. When Additional signs and symptoms present with rash. The Centers for symptomatic, common features can include fever, seizures, Disease Control and Prevention include microcephaly, intrauterine generalized lymphadenopathy, reports that the incidence of growth restriction, jaundice, thrombocytopenia, mononuclear congenital syphilis in the United Downloaded from www.aappublications.org/news by guest on September 25, 2021 2 STEWART et al States is 11.65 cases per 100000 cortical atrophy or seizures. If stable, meningitis is a potentially newborns. present, the rash in both HSV and devastating consequence of TORCH Congenital rubella syndrome can VZV is vesicular in nature. The infections and bacterial sepsis, include sensorineural hearing Centers for Disease Control and so lumbar puncture should be loss, ocular disease (‍cataracts, Prevention reports that the incidence considered. I would be inclined congenital glaucoma), cardiac of congenital varicella in the United to start empirical treatment with defects, bone disease, hemolytic States is 0.4% to 2‍.0% of newborns broad-spectrum antibiotics for “ ” anemia, thrombocytopenia, born to mothers with varicella in the possible bacterial sepsis and blueberry muffin rash, or first or second trimester. Neonatal antiviral agents for possible HSV varicella, a much more severe and or VZV. Lastly, I would consider petechiae and purpura caused3 by dermal