Erythematous Subcutaneous Nodules and Plaques in a Young Infant (Questions)

A 2-month-old male baby presented with multiple, reddish-colored, raised lesions on the body, present from 1 to 2 weeks after birth. The baby, born to a primigravida mother, out of nonconsanguineous marriage at 38 weeks through lower segment Cesarean section was admitted to the neonatal intensive care unit since birth due to delayed cry with fever, respiratory distress, and abnormal body movements. The skin lesions appeared simultaneously on all the affected sites and were not increasing in size or number. At presentation to us, the baby was lethargic, febrile (temperature 103°F), pulse 120/min, with respiratory rate 56/min, blood pressure 80/50 mmHg, and SpO2 99% on nasal prongs. There was no cyanosis, icterus, or edema. Anterior fontanelle was open and bulging. Cutaneous examination revealed multiple, well-defined erythematous nodules and plaques over the face, neck, chest and back, ranging from 1 cm to 7 cm [Image 1]. On palpation, the lesions were firm in consistency, subcutaneous, mobile, nonfluctuant with no pus points, and not fixed to underlying deeper structures, and local temperature was not raised. Over the next few days, the lesions ulcerated and discharged yellow-colored viscid fluid. Salient routine investigations showed hemoglobin 9.8 g/dL, total leukocyte count 10,200/mm3 (neutrophils 70%, lymphocytes 25%), platelets 24,000/mm3, bilirubin (total/direct) 1.23/0.73 mg/dL, total protein/albumin 3.17/1.64 mg/dL, urea/creatinine 33/0.25 mg/dl, and sodium/potassium 139/4.2 meq/L. Cerebrospinal fluid examination showed a total count of 80 cells, lymphocytes 70%, protein/sugar 750/33 mg/dL; culture showing growth of Acinetobacter baumannii sensitive to cefoperazone/sulbactam. Ultrasound cranium revealed ventriculitis with moderate hydrocephalus and periventricular leukomalacia. A contrast-enhanced computed tomography of the brain showed sequelae of hypoxic-ischemic encephalopathy with dilated ventricles, ventriculitis with large ring-enhancing lesions in bilateral periventricular region, and cerebral white matter, suggestive of infective etiology. The infant was thus diagnosed as a case of neonatal sepsis with meningitis and ventriculitis along with reddish indurated discrete plaques over the skin.Image 1Questions Identify the skin condition in Image 1 What investigation would confirm the skin condition; name one biochemical derangement associated with this condition? Name 2 maternal and fetal risk factors for this What is the management of the skin condition? Answers to the questions may be mailed by readers at [email protected] The answers of the questions along with the name and affiliation of the sender of the first correct response will be published in the subsequent issue of IPCaRes, in the section of the Clinical Quiz (Answers) in the subsequent issue of IPCaRes.Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.