ABSTRACT
Introduction: This case describes a curious cutaneous finding with a unique etiology from a cultural remedy. Case Description: A 19-month-old female was brought in by ambulance for an acutely progressive abdominal rash. Three days prior to presentation, she had a febrile seizure. The next day, she continued to have low grade temperatures and developed a faint red rash on the abdomen. On the day of presentation, the mother found a dark violaceous rash on the abdomen and called 911. The patient's presenting vital signs were unremarkable except for tachycardia to 133 and lower blood pressure for age of 86/67. She was tired and irritable. She had a large welldemarcated dusky and dark plaque with central denudation over the whole abdomen and right lateral back [Figures]. She was exquisitely tender to light palpation and guarding her abdomen. The remainder of her exam was unremarkable. Given the extent of her skin injuries, differential included intra-abdominal injury, intra-abdominal hemorrhage, burn or bruise from accidental and non-accidental cause, allergic dermatitis and disseminated intravascular coagulation in the setting of sepsis. Laboratory evaluation revealed mildly low hemoglobin for age at 10.5 g/dl with low MCV 74.2fL and a leukocytosis with WBC of 18.41 x10-3 πl with neutrophil predominance. Coagulation factors were normal. CMP revealed mild acidosis with CO2 of 17 mmol/L. Imaging studies included normal: CT head and CT abdomen with mild subcutaneous edema in the anterior abdomen near the umbilicus. Additional infectious studies were negative including nasal SARS-CoV-2 PCR, blood culture and urine culture. After the work-up, findings were consistent with a second-degree burn confirmed by Dermatology and Plastic Surgery. Suspected Child Abuse and Neglect team conducted additional social history with maternal grandmother because she is the caretaker when parents are at work, given parental denial of witnessing or causing the burn. Grandmother had limited English proficiency, so history was taken using a Medical Spanish interpreter. Grandmother explained that one day prior to presentation, she used an Oaxacan folk remedy to alleviate abdominal pain in which green tomato pulp was applied like a salve. Final diagnosis was second degree burn from phytophotodermatitis. Patient's skin improved with daily dressing changes and application of silver sulfadiazine, and she was discharged home to parents. Discussion: The use of tomato salve is a unique etiology of phytophotodermatitis that has not been well-characterized. Typical vegetation that causes burn injuries include figs, lemons and common wildflowers. Tomatillos or green tomatoes contain plant psoralens that can induce a strong phototoxic reaction to ultraviolet A radiation exposure after cutaneous contact. Conclusion: We present this case to highlight the importance of conducting thorough social history in the family's preferred language and to share a unique folk practice that can present as a severe burn and mimic child abuse.
ABSTRACT
Case Report A male infant is born at 37w to a 34-year-old G3P2 mother by vaginal delivery after an uncomplicated pregnancy. Prenatal screens are negative. The patient had a birth weight of 2,620 g, with Apgar scores of 9 and 9. On day 2 after birth, had increased work of breathing which prompted transfer to a level II NICU for further management. On arrival to the unit, the infant is tachypneic with mild chest wall retractions and thick nasal secretions. A CBC and blood culture were collected and empiric antibiotic therapy was started. Respiratory viral panel and COVID test are negative. A chest radiograph shows a middle lobe opacity concerning for pneumonia (figure 1). His clinical status failed to improve and on day 4 after birth, supplemental oxygen was provided. The primary team consulted ENT and Pulmonology services. Flexible laryngoscopy showed a normal anatomy. Pulmonology recommended transferring to our NICU for a chest CT with bronchoscopy. Our differential diagnosis for this neonate with respiratory distress that fails to improve over time or with antibiotics was broad, but further testing revealed this infant's condition. A CBC, CRP and a blood gas were collected on admission and were normal. ID service was consulted. A Chest CT showed bilateral atelectasis. Bronchoscopy showed a normal anatomy. Bronchoalveolar lavage was sent. Umbilicus swab was positive for MRSA, nasal wash/sputum culture/bronchoalveolar fluid also grew moderate S. aureus. Nasal ciliary biopsy sent for electron microscopy. Positive umbilicus and nasal swab, and subsequently BAL for MRSA led to a diagnosis of MRSA neonatal rhinitis. Therapy with IV vancomycin was initiated and later changed to oral clindamycin to complete a total of 14 days of therapy. The neonate was weaned off oxygen support on day 11. His clinical symptoms improved. He was discharged on oral clindamycin with follow up appointments with pulmonology and ID clinics. His ciliary biopsy showed absence of outer and inner dynein arms, compatible with the diagnosis of primary ciliary dyskinesia (PCD) (figure 2). Genetic testing for PCD showed mutations in the DNAAF1 and CCDC40 genes. This neonate was diagnosed with primary ciliary dyskinesia (PCD) but his presentation at birth was nonspecific and the differential diagnosis was broad. There is no gold standard diagnostic test for PCD and high clinical suspicion is important. Since it is most likely an AR inheritance, screening of family members is essential. Initial management of neonates may include measures that manage the respiratory distress, airway clearance to prevent respiratory infections and treat bacterial infections. Chest physiotherapy may help if recurrent atelectasis. Flexible bronchoscopy and bronchoalveolar lavage may help both to diagnose and treat the underlying infection. Antibiotic therapy based on organism growth for exacerbations may prevent development of bronchiectasis. (Figure Presented).