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Why does she have a rash at age four weeks?

Case Presentation

Madison is a 4-week-old African-American female who presented to the clinic with a rash covering her body. She is accompanied by her mother and father. Her mother states that the rash has been present since birth, starting on Madison's face and scalp. The neonatologist and on-call pediatrician evaluated Madison at birth and noted the rash. They told Madison's mother that they were not concerned about anything life-threatening and informed her to monitor the rash. The rash has worsened over the last four weeks, spreading to Madison's chest, arms, and legs. Her mother states she has not used any creams or ointments on the rash. Both parents are concerned because they have never seen anything like this before.

History of Present Illness

Madison's mother denies a history of fever, difficulty breathing, congestion, or cough. She denies a history of poor feedings and irritability. She states the only unusual finding she has noticed is a red circular rash covering Madison's body. Although she has not seen any drainage from the rash, she has noted some crusting in some areas. She has also noted the rash in the perianal area. She denies any oral lesions. She states Madison has had normal bowel movements and wet diapers.

Birth History

Madison was born at 40 weeks gestation via vaginal delivery. Her mother denies any complications during the prenatal course and states that Madison's only complications at birth was the rash. Madison weighed 5 pounds 4 ounces. Her mother reports Madison's Apgar scores were 9 and 10.

Family History

Madison's mother denies any other family members having any recent rashes or illnesses.

Madison has a healthy 3-year-old brother. Her mother has a history of lupus but does not take any medication. Her father has type II diabetes and hypertension. Her mother denies any family history of heart disease, bleeding disorders (including sickle cell disease or trait), or lung disease.

Nutrition History

According to her mother, Madison is breastfed only. She eats about every three hours and tolerates feedings well. Her mother states, "I eat about six to eight servings of fruits and vegetables a day." She says she eats foods high in protein and calcium, and drinks mostly water and milk. She avoids spicy foods and foods high in sugar.

Physical Assessment Findings

General appearance: Madison is awake and alert.

Vital signs: Temp: 98.4 rectal, Weight: 6 lbs 8 ozs, HR: 140, RR: 48.

HEENT: Head normocephalic. Fontanelle soft and flat. Pupils equal round and reactive to light. Bilateral red reflex noted. Tympanic membranes clear bilaterally. Normal nasal mucosa. No nasal drainage noted. Moist mucous membranes. No oral lesions noted.

Integrumentary: Skin warm, dry, and intact. Noted erythematous maculopapular lesions on face, torso, arms, and legs. Some scaly lesions noted and a maculopapular erythematous rash on perianal area.

Respiratory: Respirations even and unlabored. Breath sounds clear bilaterally. No retractions or signs of respiratory distress noted.

Cardiovascular: Regular rate and rhythm. No murmurs noted. Capillary refill less than 3 seconds.

Abdomen: Abdomen soft and non-distended. Active bowel sounds noted in all four quadrants.

Neurological: Positive suck reflex. Positive startle reflex. Positive Babinski reflex. Strong cry.

Musculoskeletal: Full range of motion of all extremities. Positive hip flexion and extension without clicks. No edema or tenderness noted.

Genitalia: Noted macular papular erythematous rash. No drainage noted.

Summary

Madison is a 4-week-old female with an unusual rash. There are no other symptoms reported. Madison is otherwise healthy.

Differentials

Tinea Corporis--Fungal infection that is usually caused by Trichophyton organisms. The rash may present as multiple pustules and papules that come together to form circular hyper-pigmented plaque. There may also be a scaly red border noted (Epstein, 2007). The lesions may also spread to other areas of the body. Fungal culture was negative for Trichophyton organisms.

Urticaria--May appear as circular plaques or papules with a red halo. There may be some central clearing with these lesions. There is sometimes edema around the lesions. The lesions may have extreme pruritis (Epstein, 2007). Madison had no signs of pruritis. Her lesions were maculopapular with no central clearing. There was no edema noted.

Erythema multiforme--May appear as papular lesions that may increase to 3 cm within a few days. The lesions may have minor pruritis. The center of the lesions may appear discolored or dusky. The lower extremities are usually the areas most involved (Epstein, 2007). This rash is not common in neonates.

Cutaneous neonatal lupus erythematosus--May appear as erythematons maculopapular lesions covering face and scalp. The lesions may also appear scaly and cover the trunk and extremities. The lesions are usually photosensitive. They can occur at birth but usually occur at 4 to 6 weeks of age. Diagnosis is usually confirmed by physical findings in the neonate and detection of anti-RO/SSA and anti-La/SSB antibodies in the mother. There is no treatment for the rash. Instructions are given to avoid direct sunlight because this may make the lesions worse. The rash will resolve in 6 to 7 months. When the diagnosis is confirmed, an electrocardiogram (ECG) should also be done to rule out congenital heart block. Congenital heart block is common in neonates with cutaneous neonatal lupus (Burch, Lee, & Weston, 2002).

Diagnosis and Treatment

Madison was diagnosed with cutaneous neonatal lupus. Her ECG was normal. Her mother tested positive for anti-RO/SSA and anti-La/SSB antibodies. Treatment included instructions to keep Madison out of direct sunlight; otherwise, no other treatment was necessary. Madison's parents were informed that the rash would resolve in 7 to 8 months. A follow-up appointment was scheduled for her 2-monthold well child check up.

References

Burch, J.M., Lee, L.A., & Weston, W.L. (2002). Neonatal lupus erythematosus. Dermatology Nursing, 14(3), 158-160.

Epstein, R. (2007). Ticked off about armpit redness. Contemporary Pediatrics, 24(12), 29-35.

Additional Reading

Warner, A., Frey, K.A., & Connolly, S. (2006). Annular rash on a newborn. The Journal of Family Practice, 55(2), 127-129.

Sherita Etheridge, MSN, CRNP-PC, is a Nurse Practitioner, Children's of Alabama, and an Adjunct Nursing Instructor, University of Alabama at Birmingham, Birmingham, AL.
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Title Annotation:Critical Thinking Case Studies
Author:Etheridge, Sherita
Publication:Pediatric Nursing
Geographic Code:1USA
Date:May 1, 2013
Words:1006
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