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JAMA Dermatology Clinicopathological Challenge
April 2016

A Discordant Cutaneous Eruption in a Neonatal Twin

Author Affiliations
  • 1Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
JAMA Dermatol. 2016;152(4):463-464. doi:10.1001/jamadermatol.2015.5050

A male neonate born prematurely at 27 weeks’ gestational age was noted to have a erythematous eruption at birth. The neonate was the product of a dichorionic, diamniotic twin pregnancy. The other twin did not have any dermatalogic abnormalities. They were born to a previously healthy woman who had been hospitalized 12 days prior for tocolytic therapy. One day prior to delivery, the mother was noted to have yeast on urinalysis. The presence of epithelial cells in the sample suggested vaginal contamination. Despite tocolytic therapy, labor ultimately progressed the following day and cesarean delivery was performed owing to breech presentation of the unaffected twin. Physical examination of the affected twin revealed an afebrile, 1200 g preterm infant. Skin examination showed 100 to 200 pink papules, 0.05 to 0.2 cm in size, distributed on the trunk, extensor upper arms, and upper legs (Figure, A and B). A subset of the lesions appeared vesiculopustular, but no fluid was evident after attempted unroofing. The diaper area, hands, feet, nails, and oral mucosa were unaffected. The second twin had normal cutaneous examination findings. Laboratory analysis revealed a white blood cell (WBC) count of 6000/μL, which was composed of 21% neutrophils, 38% lymphocytes, 24% monocytes, and 5% eosinophils. Gram stain of lesional scrapings did not reveal bacteria nor WBCs, though potassium hydroxide staining showed numerous yeast forms. Lesional polymerase chain reaction was negative for herpes simplex virus. Bacterial cultures from the skin and the blood were ultimately negative. The placentas from both neonates were sent for pathologic analysis (Figure, C and D).