Visual Diagnosis: An 8-month-old Infant Who Has an Erupting Rash

Tamar Stricker; Ulrich Lips; Felix H. Sennhauser

doi:10.1542/pir.28-6-231

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Tamar Stricker, MD*
Ulrich Lips, MD*
Felix H. Sennhauser, MD, Prof.*

^*University Children's Hospital, Zurich, Switzerland

Presentation

An 8-month-old girl who has a history of atopic dermatitis diagnosed at 2½ months of age presents to the clinic with the complaint of worsening skin lesions. She had been seen by her pediatrician 10 days ago and was prescribed oral amoxicillin-clavulanic acid and oral betamethasone for a suspected bacterial superinfection of atopic dermatitis. However, soon after starting the medications, her skin lesions increased rapidly.

Physical examination reveals an ill-appearing but afebrile infant. Height and weight are normal for age. There is a marked cutaneous eruption on the face and neck (Fig. 1), characterized by large areas of red, denuded skin with occasional crusting, oozing, and bleeding on her cheeks interspersed with elevated, fluid-containing lesions. There are crops of small, round, punched-out lesions that have raised edges on her forehead and upper chest. Examination of the dorsal and palmar aspects of both hands reveals crops of punched-out and fluid-containing elevated lesions, with some appearing hemorrhagic (Fig. 2). The remainder of the physical examination findings are normal.

Figure 1.

Facial areas of denuded skin with crusting, oozing, and bleeding and fluid-containing and punched-out lesions on the forehead.

Figure 2.

Crops of punched-out lesions with raised edges on the hand.

A complete blood count demonstrates a hematocrit of 36% (0.36) and a white blood cell count of 11.6×10³/mcL (11.6×10⁹/L) with 58% neutrophils, 27% lymphocytes, and 14% monocytes. Platelet count is 471×10³/mcL (471×10⁹/L). A serum C-reactive protein measurement is 33 mg/L. A culture of a skin lesion confirms the diagnosis.

Diagnosis:

Eczema Herpeticum

A viral culture of fluid obtained from a skin vesicle grows herpes simplex virus (HSV) that is confirmed by fluorescent antibody staining, which detected HSV …