Visual diagnosis: three infants who have perioral and acral skin lesions.

1. Douglas Leonard, MD1 2. Rafet Koca, MD2 3. Ceyda Acun, MD3 4. Saniye Cinar, MD2 5. Emel Esturk, MD2 6. Gonca Ustundag, MD4 7. Sarah Herron, DO5 8. Mark M. Butterfly, MD5 9. Joseph A. Zenel, MD1 1. 1(Case 3) Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Ore 2. 2(Case 1) Department of Dermatology, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey 3. 3(Case 1) Department of Pediatrics, Brown University, Hasbro Children's Hospital, Providence, RI 4. 4(Case 1) Department of Pediatrics, Zonguldak Karaelmas University, School of Medicine, Zonguldak, Turkey 5. 5(Case 2) Advocate Hope Children's Hospital, Oak Lawn, Ill A 5-month-old exclusively breastfed boy presents with a 2-month history of mild diarrhea and perioral, facial, scalp, and perineal skin lesions. The skin lesions first began around the corners of the mouth and the back of his head and later appeared over his perineum and buttocks. Despite treatment with topical antibiotic and antifungal agents as well as systemic antibiotics prescribed by primary care practitioners, the lesions did not improve. In fact, within the past few days, he has developed small blisters on his hands and feet. The infant weighed 3,900 g at birth and was born at term. Similar skin lesions, with the same distribution, appeared in an older brother when that brother was 4 months of age. The older brother's rash resolved after he was weaned from breastfeeding. Physical examination reveals an alert child whose vital signs are within normal limits. There are erythematous, scaly, crusting plaques on the facial cheeks and perioral region; the occiput; the hands and feet; and over the scrotum, penis, and buttocks (Figs. 1, 2). Vesiculobullous lesions that have erythematous borders are on the wrist and ankles. The remainder of the physical findings are within normal limits. Figure 1. Erythematous, scaly, and crusting plaques on the facial cheeks, perioral region, and occiput. Figure 2. Erythematous, scaly, and crusting plaques over the scrotum, penis, and buttocks. Laboratory examination reveals normal complete blood count, serum electrolyte concentrations, alanine transaminase, aspartate transaminase, blood urea nitrogen, and creatinine as well as urinalysis, stool examination, serum immunoglobulins, chest radiograph, and abdominal ultrasonography. Testing for antiendomysial antibody and antigliadin antibodies (IgA and IgG) is negative. The serum alkaline phosphatase level is 50 U/L (normal, 85 to 270 U/L). Additional serum testing reveals the diagnosis. An 8-month-old African-American male presents to the emergency department with fever and worsening eczema. He was diagnosed as having …