The Journal of the Arkansas Medical Society Med Journal Aug 2019 Final 2 | Page 20

CASE STUDY
Editors Note: Article re-published from the June 2019 issue with case photos.
Blueberry Muffin Rash in a Neonate
David N. Matlock, MD; 1, 2 Franscesca Miquel-Verges, MD 1, 2
UAMS, Little Rock
Arkansas Children’s Hospital, Little Rock
1
2
A
36-week newborn, followed
prenatally for an enlarged liver,
microcephaly,
and
Dandy-
Walker malformation, was delivered by
caesarean section due to non-reassuring
fetal heart tones to a 25-year-old G1
mother without significant past medical
history. The mother had appropriate prenatal
care, and the pregnancy had been complicated
only by the abnormal ultrasound findings and
an afebrile exanthema, which occurred during
the first trimester. The infant was noted to
have jaundice, a purpuric rash with petechiae
(Panels A and B), and hepatosplenomegaly.
Cranial sonography revealed punctate
foci in the periventricular white matter.
Echocardiogram revealed a moderate
pericardial effusion. She had hepatitis
with a direct bilirubin of 19, disseminated
intravascular coagulopathy with severe
thrombocytopenia (platelet count was
21,000), and respiratory failure. She had
elevated serum IgG and IgM titers as well as
a positive urine polymerase chain reaction for
cytomegalovirus.
Magnetic resonance imaging of the brain
revealed microcephaly with diffuse cerebral
volume loss, periventricular calcifications,
and neuronal migration abnormalities.
Hearing screens were failed bilaterally.
Thrombocytopenia responded to multiple
platelet transfusions. Neutropenia developed
during antiviral treatment and required
multiple doses of granulocyte-monocyte
colony stimulating factor.
The infant completed a six-week course of
intravenous ganciclovir before transitioning to
oral valganciclovir. She was discharged
from the neonatal intensive care unit
on room air, taking full oral feedings
at seven weeks of life. She is enrolling
in developmental therapies and will
require close follow-up of her growth
and development.
While usually asymptomatic,
10% of newborns with congenital
cytomegalovirus infection will have
manifestations at birth. Among
symptomatic patients, multi-organ
involvement is common and a
small subset present with life-
threatening disease. The preferred
diagnostic tests are viral culture or
polymerase chain reaction in urine.
Treatment with ganciclovir (IV) is
44 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
recommended. Once stable, treatment can
be provided orally (valganciclovir). Mortality
remains high at 3-10% for newborns with
symptomatic disease. Sequelae are common,
specifically sensorineural hearing loss and
neurodevelopmental disability. 1
1. American Academy of Pediatrics.
Cytomegalovirus Infection. In: Kimberlin
DW, Brady MT, Jackson MA, Long SS, eds.
Red Book: 2018 Report of the Committee
on Infectious Diseases. American Academy
of Pediatrics; 2018; 310-317.
Magnetic resonance imaging of
the brain revealed microcephaly
with diffuse cerebral volume loss,
periventricular calcifications, and
neuronal migration abnormalities.
VOLUME 116