Rash, Hemolytic Anemia, and Elevated Transaminase Levels in a 2-month-old Girl

Alex Plattner; Sarah Greene; Elizabeth Nieman

doi:10.1542/pir.2019-0273

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Alex Plattner, MD*
Sarah Greene, MD, PhD^†
Elizabeth Nieman, MD^‡

^*Department of Pediatrics, St Louis Children’s Hospital, Washington University, St Louis, MO
^†Division of Infectious Diseases, Department of Pediatrics, St Louis Children’s Hospital, Washington University, St Louis, MO
^‡Division of Dermatology, Department of Internal Medicine, Washington University, St Louis, MO

AUTHOR DISCLOSURE
Dr Nieman’s current affiliation is Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC. Drs Plattner and Greene have disclosed no financial relationships relevant to this article. Dr Nieman is involved in clinical trials with AbbVie and Pfizer. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A 2-month-old, previously healthy girl presented to the emergency department (ED) after being referred by her pediatrician for evaluation of fever and rash. The rash first began at 1 month of age and started as 4 “big and red” spots: 1 each on her face, leg, chest, and back. She was seen in her pediatrician’s office 4 days after the initial symptoms and was prescribed hydrocortisone cream for eczema, with initial improvement. One week later, the patient developed a fever and runny nose, followed by a new rash that was more diffuse across the body and involved the hands and feet (Fig 1). She continued to apply hydrocortisone cream, without improvement, but had ongoing runny nose. At her 2-month health supervision visit she had ongoing runny nose and 2 days of congestion and fever (102°F [38.9°C]). The infant had normal oral intake and urine output, with no change in mental status. The mother denied infant exposure to sick contacts, recent changes in detergents or skin care, and recent travel.

Figure 1.

Evolving lesions found on the patient’s left lower extremity.

The infant was born at 37 weeks and 1 day of gestation via cesarean delivery due to maternal pancreatitis but had a normal newborn course, including a normal newborn screen. Maternal serologic testing during pregnancy was notable for equivocal rubella titer but nonreactive for hepatitis B surface antigen, herpes simplex virus, VDRL/rapid plasma reagin (RPR), and human immunodeficiency virus, all obtained during the …