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

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CASE STUDY
Blueberry Muffin Rash in a Neonate
David N. Matlock, MD; 1, 2 Franscesca Miquel-Verges, MD 1, 2
Call
Pharmacist/Attorney
Darren O’Quinn
1-800-455-0581
www.DarrenOQuinn.com
Little Rock, Arkansas
UAMS, Little Rock
Arkansas Children’s Hospital, Little Rock
1
2
A
36-week newborn, followed
prenatally for an enlarged liver,
microcephaly, and Dandy-Walk-
er malformation, was delivered by cae-
sarean section due to non-reassuring
fetal heart tones to a 25-year-old G1
mother without significant past medi-
cal history. The mother had appropriate
prenatal care, and the pregnancy had been
complicated only by the abnormal ultra-
sound 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 peri-
cardial effusion. She had hepatitis with a
direct bilirubin of 19, disseminated intra-
vascular coagulopathy with severe throm-
bocytopenia (platelet count was 21,000),
and respiratory failure. She had elevated
serum IgG and IgM titers as well as a posi-
tive urine polymerase chain reaction for
cytomegalovirus.
Magnetic resonance imaging of the
brain revealed microcephaly with diffuse
cerebral volume loss, periventricular cal-
cifications, and neuronal migration ab-
normalities. 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.
284 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Magnetic resonance imaging of
the brain revealed microcephaly
with diffuse cerebral volume loss,
periventricular calcifications, and
neuronal migration abnormalities.
The infant completed a six-week course
of intravenous ganciclovir before transition-
ing 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 thera-
pies 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. Treat-
ment with ganciclovir (IV) is 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 neurodevel-
opmental disability. 1
1. American Academy of Pediatrics. Cyto-
megalovirus 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.
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