A Young Infant with a Common Skin Condition: Any Underlying Serious Cause or Not?

• A two-month-old baby boy from Maung Daw, Rakhine State presented to our hospital with a history of Itchy skin rashes and bilateral ear discharge on and off for more than six weeks.
• The mother reported that the (vesicular) rashes appeared around the lips and eyes since he was 10 days old, followed by those on the scalp, periumbilical and buttock areas.
• The baby had associated symptoms such as foul-smelling ear and umbilical discharge.
• There were no other features like fever, bleeding manifestations and respiratory or gasrointestinal symptoms.
• The prenatal and perinatal histories are not relevant apart from maternal Covid 19 infection at 34 weeks of gestation.
• The baby is the second-born child of a consanguineous marriage.
• There is no family history of atopy and malignancy and autoimmune disorders.

• The baby has been on formula feeding since birth
• He is developmentally-age appropriate and has received BCG vaccination.
• On examination, the baby was active, alert and afebrile, with weight, height and occipitofrontal circumference on 50th centile.
• Dry scaly lesions were found on the scalp, eyebrows, periorbital, perioral, postauricular, peri umbilical areas and buttocks.
• There was ear discharge and umbilical discharge as well
• Systemic examination showed no other abnormalities like lymphadenopathy and organomegaly and normal findings of heart and lungs.
• The following investigations were done
• Full blood count

24/12/22• ESR – 15mm/1^st hr

• Swab C&S – Moderate growth of Staph. pseudointermedius isolates
• Anti-Schistosoma antibody – Negative
• COVID-19 Antibody – Negative

1/1/22• Ferritin – 510 ng/ml (30-400 ng/ml)

• JAK 2 mutation – Negative (to diagnose bone marrow disorder)
• IgE level – 389 IU/ml (1 – 2 months <15IU/ml )
• Specific IgE for Paediatric Allergen – Bovine serum albumin Class 1(very weak antibody detected)
• Serum Zinc level – 70.79 ug/dl (55 – 92 ug/dl)
• The baby was treated by a team of pediatricians, haematoncologist and dermatologist and received the following medication
  – IV flumox (Flucloxacillin and Amoxicillin) 100 mg 8 hly
  – PO Paracetamol 100 mg/1_ml 0.7 ml PRN
  – PO Predisolone (5 mg / _tablet , ½ tablet BD x 2 weeks followed by ½ OD alternate days for 2 weeks
  – PO Omeprozole (20 mg / Capsule) ¼ OD
  – PO Loratidine 2 mg HS
  – Supirocin ointment to the vesicles
  – Halykoo zinc cream to perineal region
  – Ciprofloxoin ear drops (2) drops BD
  – Olive Oil
  – 1% Hydrocortisone cream
  – Nutramigen (Hypoallergenic milk formula) was not taken so standard milk formula was continued.
• The symptoms improved gradually and he was discharged after 4 days
• The baby was followed up by the respective specialities
• The following is the recently taken picture of the baby

Discussion

• We consider the following differential diagnoses in this baby as the high eosinophil count and raised immunoglobin E level were significant laboratory findings.
  (a) Allergic disorders (Atopic dermatitis with associated cow’s milk allergy)
  (b) Seborrhoeic dermatitis
  (c) Neoplastic disorders (Langerhans cell histocytosis)
  (d) Immune disorders (Hyper Ig E syndrome, severe combined immunodeficiency, Wiskott Aldrich Syndrome)
• The baby lacks any systemic features like fever, failure to thrive, bleeding diathesis, lymphadenopathy and organomegaly
• There were no sinopulmonary infections and any skeletal ahnomalities seen in neoplastic and immune disorders.
• The eosinophil counts were decreasing with time on treatment with prednisolone together with the resolution of skin symptoms.
• The serum Ig E was increased to twice the age-reference range but not as high as 1000 or 50,000 IU/ml as seen in hyper Ig E syndrome^.2
• The skin manifestations follow the pattern of seborrhoeic dematitis where it may not be itchy in contrast to atopic dermatitis with no rise in esonophil and serum IgE. But these two conditions can coexist.¹
• The baby developed weak antibody titre to bovine serum albumin which is specific serum IgE to milk protein.
• Cow’s milk allergy should be considered if we come across a young infant with moderate to severe atopic dermatitis in which cow’s milk formula can exacerbate or prolong the skin symptoms if the baby is formula-fed or if the mother is taking dairy products while breastfeeding the baby.³
• In this baby, the serum specific IgE was not high but cow’s milk allergy can also be mediated by non-IgE component which we cannot investigate easily (e.g Patch test or other non-IgE tests).³

Conclusion

• It is quite a common occurrance that young infants present with recurrent eczematous skin lesions.
• In view of the abnormalities in blood and serum marker of immune and allergic disorders, we should investigate further not to miss the sinister cause such as malignancy and immune disorders.

References

1. William L weston, MD, William Howe MD, overview of dermatitis (Eczema), up to date February 2022, Topic 1727 version 16.0
2. Peter F weller, MD, MACP, Any D kilion, MD, Approach to the patient with unexplained eosinophilia, Up to date.com February 2022, Topic 5691 version 27.0
3. Yvan Vandenplas, Martin Brueton, Christophe Dupont, Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Archives of disease in childhood, 2007; 92:902-908.

Author Information

Aye Aye Khine¹, Hnin Thuzar Aung², Zar Phyu Kyi³, Aung Myo Min⁴

1. Professor Haematology & Oncology Department (Yangon Children Hospital)
2. Consultant Paediatrician, (Parami General Hospital)
3. Consultant Dermatologist
4. Senior Medical Officer, (Parami General Hospital)