Think of syphilis first with suspicious newborn dermatoses: herpes simplex virus another possibility.
"I have missed cases of congenital syphilis and called it something different, because unless you have it very close to the front of your mind, you're not going to make the diagnosis," said Dr. Treadwell, a pediatric dermatologist at the Riley Hospital for children, Indianapolis.
Other telltale symptoms include maculopapular or papulosquamous eruptions and rhagades. Splenomegaly and periosteal inflammation of the long bones and ribs may also occur.
She added that when disease invades the bone marrow, the infant can develop skin lesions that resemble blueberry bits. Diagnosis is confirmed by serologic tests or when scraping of the skin lesions reveals Treponema pallidum.
The recommended treatment, according to the 2003 Red Book, is to administer 100,000-150,000 U/kg per day of aqueous crystalline penicillin G in dosages of 50,000 U/kg IV every 12 hours during the first 7 days of life, then every 8 hours for a total of 10 days. Another treatment option is penicillin G procaine in dosages of 50,000 U/kg per day IM for 10 days.
Dr. Treadwell discussed two other newborn dermatoses that warrant careful attention:
* Herpes simplex virus. Defining characteristics include grouped, vesicular lesions that may also have crusting and ulceration. "This is different from less serious skin disorders in that there is surrounding erythema," she said at the meeting. "The blister that occurs is in the lower epidermis, so these lesions are a little bit deeper than what we tend to see with other lesions."
Diagnosis of HSV-1 or HSV-2 is made by Tzanck smear, fluorescent antibody, or culture. If the infant has blistering lesions, you can acquire a culture sample by rupturing one of the blisters. "What I do is open the blister and use a [cotton swab] to retrieve a sample," she said.
"The fluid inside is not what's important. The viral particles are at the base of the lesion. I send the [cotton swab] in the viral media and get a culture back in 12-24 hours."
The only FDA-approved treatment in children is acyclovir. "There is not a preparation of valacyclovir and famciclovir that is approved in children, so acyclovir is really the only choice," Dr. Treadwell said. "Optimal management for recurrences has not been established."
* Neonatal lupus erythematosus. About 40% of infants with this condition present with cutaneous lesions, about 40% present with cardiac abnormalities, and the rest have both. "This disease occurs because of the transplacental spread of maternal antibodies," she said. "A number of the mothers will be asymptomatic, but some will have a diagnosis of Sjogren's syndrome."
Evaluate the infant and mother for anti-Ro / SSA, anti-La / SSB, and anti-RNP antibodies.
"The cardiac abnormalities occur at 9-10 weeks of gestational age, and the antibodies have to be present at that time," she said. "The antibodies bind to the fetal myocytes and the cells of the conduction system. Some of these children are picked up prior to birth because of the bradycardia."
Dermatologic signs of neonatal lupus erythematosus at birth may include annular lesions, discoid lesions, and atrophic lesions. Telangiectasias can occur later.
"It is important to get an EKG on these children," she said. "The third-degree heart block is usually diagnosed prior to birth because of bradycardia, but they may have other degrees of heart block."
Lesions may be triggered by sun exposure, but they generally clear by 6-12 months of age. Protect babies from the sun and use topical hydrocortisone if necessary
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|Title Annotation:||Infectious Diseases|
|Date:||Jun 1, 2004|
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