Rare Serious Infections in Afebrile Infants with Skin Lesions: Insights from a Retrospective Study

Core Concepts

Afebrile full-term infants with pustules or vesicles have a low risk of life-threatening infections, except for herpes simplex virus (HSV) infection, which requires targeted testing.

Abstract

This retrospective study examined the risk of serious infections in afebrile infants aged ≤ 60 days who presented with skin lesions such as pustules, vesicles, and/or bullae. The researchers reviewed the electronic medical records of 879 infants who received a pediatric dermatology consultation at six US academic institutions between September 2013 and August 2019.
Key findings:

183 afebrile infants were identified as having presented with skin lesions.
67.8% had pustules, 31.1% had vesicles, and 10.4% had bullae.
None of the cases showed positive cerebrospinal fluid or pathogenic blood cultures, indicating a low likelihood of life-threatening infections.
In 66.6% of cases, a noninfectious cause was diagnosed, while an infectious cause was diagnosed in 38.8% (some patients had more than one diagnosis).
7.1% of the 127 infants evaluated for HSV infection tested positive, with 5.5% having disease affecting the skin, eye, and mouth (full-term infants) and 1.6% having disseminated HSV (preterm infants).
Angioinvasive fungal infection was diagnosed in 2.7% of infants, all of whom were preterm (< 28 weeks gestational age).
The risk for life-threatening disease was higher in preterm infants born before 32 weeks of gestational age compared to those born after 32 weeks.
The authors concluded that full-term, well-appearing, afebrile infants ≤ 60 days of age presenting with pustules or vesicles may not require a full serious bacterial infection (SBI) workup, although larger studies are needed. Testing for HSV is recommended in all infants with vesicles, grouped pustules, or pustules accompanied by punched out or grouped erosions, and preterm infants should be assessed for disseminated fungal infection and HSV in the setting of fluid-filled skin lesions.

Stats

None of the cases showed positive cerebrospinal fluid or pathogenic blood cultures.
7.1% of the 127 infants evaluated for HSV infection tested positive.
5.5% of the HSV-positive infants had disease affecting the skin, eye, and mouth (full-term infants).
1.6% of the HSV-positive infants had disseminated HSV (preterm infants).
2.7% of infants were diagnosed with angioinvasive fungal infection, all of whom were preterm (< 28 weeks gestational age).
The risk for life-threatening disease was higher in preterm infants born before 32 weeks of gestational age compared to those born after 32 weeks.

Quotes

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Key Insights Distilled From

Serious Infections Rare in Infants With Pustules, Vesicles

by Edited Satis... at www.medscape.com 07-04-2024

https://www.medscape.com/viewarticle/life-threatening-infections-rare-full-term-infants-pustules-2024a1000cdy

Deeper Inquiries

What are the potential underlying causes for the noninfectious skin lesions observed in the majority of cases?

In the study, the majority of cases with noninfectious skin lesions were diagnosed with conditions such as miliaria, transient neonatal pustular melanosis, and neonatal cephalic pustulosis. Miliaria, also known as heat rash, occurs due to blocked sweat ducts, leading to pustules. Transient neonatal pustular melanosis is a benign condition characterized by vesicles and pustules that resolve without treatment. Neonatal cephalic pustulosis is another common noninfectious cause, presenting as pustules on the face and scalp. These conditions are typically self-limiting and do not require extensive infectious workups.

How can the findings of this study be used to develop more targeted and efficient diagnostic protocols for evaluating skin lesions in afebrile infants?

The findings of the study suggest that in full-term, afebrile infants with pustules or vesicles, a full serious bacterial infection (SBI) workup may not be necessary. Instead, focusing on testing for herpes simplex virus (HSV) in infants with specific skin lesion presentations can lead to more targeted and efficient diagnostic protocols. The study recommends testing for HSV in infants with vesicles, grouped pustules, or pustules accompanied by erosions. By following these guidelines, healthcare providers can streamline the diagnostic process, avoid unnecessary tests, and promptly identify potential infectious causes in infants with skin lesions.

Given the low incidence of serious infections, what other factors beyond gestational age may contribute to the risk of life-threatening disease in infants with skin lesions?

Beyond gestational age, other factors that may contribute to the risk of life-threatening disease in infants with skin lesions include the presence of comorbidities, immune status, and the overall health of the infant. Infants with underlying medical conditions or compromised immune systems may be at a higher risk of developing severe infections. Additionally, environmental factors, such as exposure to pathogens or inadequate hygiene practices, can also play a role in increasing the risk of life-threatening diseases in infants with skin lesions. Healthcare providers should consider these factors when evaluating and managing infants with skin lesions to ensure appropriate care and timely intervention.