PMID: 10530594

Issn Print: 0891-3668

Publication Date: 1999/10/01


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ULCERATIVE LESION OF THE NASAL BRIDGE IN A FIVE-MONTH-OLD INFANT

Andrew J. Daley; Peter McIntyre; Alyson Kakakios; David Isaacs

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Excerpt

A 5-month-old boy was admitted for management of an ulcerated, crusted lesion on the bridge of his nose with satellite nodular lesions extending onto his cheek. He had suffered a small abrasion from a plastic toy 3 weeks earlier, and a cystic, fluctuant swelling had developed on the bridge of his nose after several days. The cystic lesion was incised at a peripheral hospital, and cloudy fluid was obtained. The fluid contained scanty polymorphonuclear neutrophils; no organisms were seen on Gram-stained smear, and the fluid was sterile on bacterial culture. After this and despite oral cefaclor the lesion gradually enlarged and became indurated with superficial crusting and purulent discharge. He was referred to this hospital because a fistula was thought to have developed between the lesion and the nasal cavity.
His 35-year-old mother had discoid lupus erythematosus diagnosed at 17 years of age and had active skin lesions treated with hydroxychloroquine and low dose prednisolone (5 mg daily) during pregnancy (Fig. 1). The pregnancy was also complicated by gestational diabetes managed by diet alone. He was the fourth child of his mother, but the first with her current partner. An 18-year-old stepsister and 16-year-old stepbrother were in good general health, but another stepsister had died at 2 days of age with multiple congenital abnormalities of undetermined etiology. His mother had also had several miscarriages and an ectopic pregnancy. His father had no siblings and was working part-time in an abattoir.
The child was born at term by elective cesarean section for breech presentation with a birth weight of 2840 g. He was slow to establish bottle feeding, had intermittent watery stools, was difficult to console and cried for long periods. He was first seen at 4 weeks of age with extensive oral ulceration, poor feeding and suboptimal weight gain. After topical nystatin caused no improvement, he was treated with topical miconazole; the ulcers gradually resolved during the next 3 weeks. Specimens for viral culture were not obtained. The mouth ulcers recurred at 2 months of age, with associated diffuse pharyngitis, irritability, frequent posseting and poor feeding. Investigations showed normal hemoglobin and red blood cell values but a low serum iron, high ferritin and slightly elevated gamma-glutamyltransferase, thought to be consistent with an acute infection. Subsequently iron studies returned to normal, although the gamma-glutamyltransferase remained elevated. Neonatal lupus syndrome was considered but immunoglobulins G, M and A and antinuclear antibody were normal.
At the time of admission the baby was afebrile and active with a weight of 6.9 kg which followed the 25th percentile. An ulcerated, crusted lesion with surrounding cellulitis was present on the bridge of his nose and discharging a small amount of serosanguinous fluid (Fig. 2). Fluid of similar appearance was discharging from his left nostril. Examination of the ears and throat was normal and there was no regional lymphadenopathy. The spleen was palpable 2 cm below the left costal margin and he had mild diaper dermatitis.
He was initially treated with intravenous flucloxacillin, 50 mg/kg/dose four times daily, for presumed staphylococcal infection. Immunofluorescence for herpes simplex virus types 1 and 2 was negative as were viral cultures. Superficial swabs from the nasal lesion grew Serratia marcescens. Moraxella catarrhalis and Streptococcus pneumoniae were isolated from the nasal discharge. During the next 48 h superficial nodular erythematous satellite lesions spread onto his cheeks in a butterfly distribution. When the surface swabs grew S. marcescens, his antibiotics were changed to gentamicin 7 mg/kg/day and trimethoprim- sulfamethoxazole (4.5/ 23 mg/kg/dose twice a day).
Hemoglobin was 9.2 g/dl and total white cell count 19.5 × 109/l with 12.
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