Neonatal Rash, to Swab or Not to Swab

By Latoya Alexia Bethell, Nelofer Jawadi, Andrea Davila, Sarah Alzaroui, Vernee Labega, Marylynda Ogbudinkpa

A previously healthy 3-week-old girl presented to her pediatrician with lesions on her forehead and perianal region, with no fever or purulent drainage. Additionally, she developed a mild nasal congestion and irritability, but no further symptoms. After evaluation, the infant was referred to the Pediatric Emergency Department for a neonatal sepsis work-up with high suspicion of HSV infection. Her mother had a history of genital warts. At time of presentation, the neonate had no hepatosplenomegaly, lymphadenopathy, or rash anywhere else, and presented with normal tone, strength, and open, flat anterior and posterior fontanelles. Pending the septic work up, the patient was started on empiric intravenous ampicillin, gentamicin, and acyclovir in addition to being admitted to the NICU for further treatment. A complete neonatal sepsis rule out was performed with no abnormalities. A lumbar puncture produced blood-tinged fluid on the second attempt and no organisms were seen through CSF Gram stain. However, the final diagnosis was concluded when PCR test came back as positive for Varicella Zoster Virus (VZV) in only the skin lesion and blood. VZV most commonly affects young children who are not immunized against the disease. It presents with a pruritic rash with vesicles and is most often accompanied by fever, malaise, and decreased appetite. In this case, having an infant with VZV and no prior history of exposure from either parent, it is important to explore the methods and management of exposure. Additionally, the lack of typical clinical presentations in the neonatal age group and initial negative findings made the definitive diagnosis of VZV harder. VZV is not typically part of a complete neonatal sepsis work up. This case calls for awareness and high level of clinical suspicion in order to diagnose such a critical disease in such young and vulnerable patients.

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