Skin lesions in an extremely low birth weight newborn with Staphylococcus aureus

A male newborn born of non-consanguineous marriage was delivered by a lower segment cesarean section at 28 weeks gestational age due to chorioamnionitis after a premature rupture of the membranes at 24 weeks of gestation. The mother received antibiotics and antenatal corticosteroid therapy for fetal maturation. The prenatal serological screening for rubella, toxoplasmosis, hepatitis B, syphilis and HIV was negative in the mother and antenatal ultrasounds in the mother at the 12^th week, 22^nd week and antepartum were normal. Birth weight of the newborn was 900g, and Apgar scores were 3, 7 and 8 at 1, 5 and 10 minutes, respectively. He required orotracheal intubation and positive pressure ventilation. He was admitted at the neonatal intensive care unit (NICU) of a tertiary hospital for invasive ventilation, which was maintained for 10 days, and for antibiotic therapy. On the 34th day of life (33 weeks of gestational age), a small erosion with yellow crusts was noted on the columella, related to the nasal prongs of non-invasive ventilation. Hours later, he developed diffuse erythema on the left arm and hand, where IV access was attempted before, which subsequently led to skin shed from the glove area (Figure 1). Nikolsky’s sign was positive. Mucous membranes were spared. He was started on oral linezolid (in the absence of IV access) and analgesics (opioids). Wound care was managed with soft silicone bandages. Over the first 24 hours, there was a progression of the bullous lesion to the inguinal folders, perianal region and limbs, and all of them peeled off in sheets. Simultaneously, the nasal plaque became larger and exudative with honey crusts, probably due to the nasal mask of continuous positive airway pressure ventilation (Figure 2). For this reason, he required invasive ventilation. He remained hemodynamically stable and without fever. Skin culture obtained from the nose lesion was positive for methicillin-susceptible Staphylococcus aureus (MSSA) and antibiotic therapy was changed to intravenous flucloxacillin. Blood culture and septic screen reports were negative. No further skin lesions or desquamation developed after two days of intravenous antibiotic therapy. After three days, the newborn developed respiratory distress and the chest radiograph showed right lung consolidation. Klebsiella oxytoca was isolated in the respiratory culture, and intravenous antibiotic therapy was replaced to meropenem and linezolid. The skin healed without any scars in a week (Figure 3). In the NICU, the closest neonate also had MSSA infection with cutaneous pyogenic abscesses in the upper limbs and endocarditis.

Figure 1. Diffuse erythema on the left arm and hand which led to skin shed from the glove area.

Figure 2. Large and exudative nasal plaque with honey crusts (probably due to the nasal mask of continuous positive airway pressure ventilation)


What were the skin lesions?