Recurrent rash in a 2‐month‐old

Abstract

A 6-month-old boy with history of prematurity (born at 33 weeks gestational age), congenital cataracts, hypertelorism, micrognathia, cryptorchidism, dysplastic aortic valve, solitary renal cyst, DandyWalker malformation status post-ventriculoperitoneal shunt, protein-losing enteropathy, and difficulty feeding presented for recurrent rash. The first episode of rash occurred approximately two weeks after discharge from the neonatal intensive care unit at 7 weeks of age. The rash subsequently recurred two times over the next three months, each time following initial improvement on oral antibiotics. Physical examination during the first hospitalization showed a pinkred plaque with overlying golden yellow scale, crust, and erosions on the left cheek, orbital ridge, frontal, temporal, and posterior scalp without vesicles, bullae, or pustules. His trunk and extremities were unaffected. His hair was noted to be very sparse. During his second hospitalization, the rash had a very similar morphology and distribution except for new erythema containing a solitary bulla on the antecubital fossa and left popliteal fossa with sharp demarcation lines (Figures 1-2). A biopsy showed a “pauci-inflammatory subcorneal blister compatible with staphylococcal scalded skin syndrome.” However, numerous blood and skin cultures were negative, including for Staphylococcus. Four days after discharge from the second hospitalization, he developed another eruption with similar morphology and distribution. The patient was subsequently admitted to the hospital for failure to thrive. He was breastfed, was up-to-date on immunizations, had never been diagnosed with any infections, and had no family history of skin or other genetic conditions.