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

Medical Board Legal Issues? 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 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. VOLUME 115