What’s the diagnosis?

A previously healthy 8-week-old male born at term by vaginal delivery presented with a history of a temperature of 101 F. There were no constitutional symptoms such as cough, cold, vomiting, etc. There were also no known infectious exposures. On admission to the ED, a COVID-19 test was negative.

The only other complaint was a peeling rash that had been present for one week. It began on the head, spread to the trunk and was now desquamating, leaving hypopigmented areas of epidermis (see figures).

There were no pustules, vesicles or other skin findings. The mother denied any abnormal prenatal labs. She was GBS negative and was known sickle trait positive. The baby’s newborn screens were normal.

On physical exam, the vital signs revealed a temperature of 100.5 F rectally, pulse rate of 175, respiratory rate of 64 and normal blood pressure. Oxygen saturation was 97% on room air. The baby did not appear toxic but did appear pale. Pertinent findings on the exam included a small umbilical hernia, generalized desquamating rash, mild edema noted pretibially and mild hepatomegaly.

Lab results included a CBC with a WBC of 12,300 with a left shift. Hemoglobin was 5.1g/dL, hematocrit 19% and platelet count 308k. On peripheral blood smear, polychromasia and nucleated RBCs were noted. A serum albumin was 1.9g/dL. CRP was 157mg/L and procalcitonin 2.3ng/mL. A cath urine revealed moderate blood with 3+ protein. Urine microscopy was positive for 32 WBC/ hpf and 34 RBC/hpf.

What’s your diagnosis?

A. Autosomal recessive polycystic disease (ARPD)

B. GBS bacteremia

C. Congenital syphilis

D. Langerhan’s histiocytosis

E. Listeriosis

Have you figured out the diagnosis?

See Page 29 for the answer.