TICK WITH TREAT

Ticks can determine various local reactions, among which scarring and nonscarring inflammatory alopecia. We describe a case of nonscarring alopecia in a two-year-old girl of Romanian origin who reported a recent history of tick bite. She referred to our pediatric department with diffuse alopecia of the scalp, in which there was an erythematous nodule, presumed site of the tick bite accursed two months prior. She did not develop fever, arthralgias or other systemic symptoms. In order to exclude autoimmune diseases and infectious etiologies, we performed laboratory exams, such as anti-thyroid, antinuclear, anti-transglutaminase, TORCH and anti-Borrelia antibodies, resulted negative. A punch biopsy specimen from the scalp (0.4×0.3×0.2 cm) revealed fibrosis of the derma and the peripheric areas of pili-sebaceous annexes. The following month, we observed a rapid centrifugal progression to total alopecia. Thus, we decided to attempt therapy with topic corticosteroids followed by a progressive hair regrowth during the following four months. Tick bite alopecia was first described in 1921. Since then, a few other cases have been reported in the international literature. The characteristic manifestation is a single zone of alopecia, often with a centrifugal spread, that appears 1–2 weeks after the tick removal. Sometimes, it can be associated with a central eschar, representing the site of tick bite. The nonscarring forms of alopecia manifest as ‘moth-eaten’ patches or, in alternative, as nodular or blood-crusted lesions. Clinically, patients may present with pain, pruritus or swelling. The precise mechanism for hair loss is not well understood but it is assumed to be caused by the host inflammatory response to tick saliva antigens. The result is the destruction of hair follicles or the alteration of the catagen/telogen phase. Histologic findings may show a heterogeneous inflammatory infiltrate and areas of fibrosis. The international literature does not report effective therapy for tick bite alopecia, while treatment with topic corticosteroids for alopecia areata is recognized. Prognosis is favourable with a complete hair regrowth usually within 3 months, although in some cases alopecia is reported to persist for 5 year

Benign neonatal pustolosis (BNP) / TO WORRY OR NOT TO WORRY

Benign neonatal pustolosis (BNP) comprehend a group of clinical diseases characterized by transient pustules or vescico-pustular lesions on newborn skin. These are asymptomatic and self-limiting conditions including benign cephalic pustolosis (BCP). A 40 days old girl was conducted to our Pediatric Unit for the appearance of multiple vescico-pustular lesions with serous sterile content on her forehead. She was born at term, had a regular perinatal period and never reported cutaneous problems. No lotions or creams for and after her baths were used and no direct contact to sunlight was described. At the time of consultation, she was in excellent health conditions. On suspicion of BCP, we did not prescribe exams or local and/or systemic treatments but indicated a strict follow-up with clinical revaluation after 3 days. At follow-up, the infant did not have clinical problems and her pustular lesions had begun to disappear. After 7 days, all pustules had completely disappeared without leaving any scar. Dermatosis that occur during the neonatal period can be infectious or sterile, such as BNP. Frequently, BNP are secondary to a physiological skin response or to environmental factors. They are benign, self-limited, asymptomatic cutaneous conditions that present during the first days of life. Their diagnosis is clinical but, sometimes, can require some investigations, principally non-invasive, to exclude more severe diseases. BNP include erythema toxicum neonatorum, transient neonatal pustular melanosis and BCP. BCP was first described by Aractingi in 1991. There is no consensus about its prevalence, which is estimated between 10% and 60%. Its presentation is asymptomatic and self-limiting and is characterized by numerous papules and pustules located on the face and scalp with onset between 5 days and approximately 3 weeks of age of the newborn. Numerous studies evaluated the possible role of Malassezia in the etiopathogenesis of BCP. Nevertheless, this correlation has not been demonstrated so far. In conclusion, the presence of pustules in newborns is always a reason of concern for parents and doctors, since neonatal skin is more vulnerable to bacterial, viral and fungal infections. These lesions can be a real challenge for clinicians who have to recognize serious diseases requiring hospitalisation from benign transient conditions, avoiding superfluous exams, treatments and worrie

HUMAN METAPNEUMOVIRUS RESPONSIBLE FOR A SEVERE ERYTHEMA MULTIFORME: AN UNUSUAL ASSOCIATION

Erythema Multiforme (EM) is an acute immune-mediated condition characterized by the appearance of typical target-like lesions on the skin. They most commonly appear in a symmetrical distribution on the extensor surfaces of the acral extremities and subsequently spread in a centripetal way. EM ‘major’ involves oral, genital and ocular mucosae with erosions or bullae. Although cutaneous lesions are usually asymptomatic, EM can be caused by drugs, autoimmune disease, malignancy, irradiation, sarcoidosis and in 90 percent of cases by infections (viral, bacterial, fungal). Herpes Simplex virus is the most frequent etiologic agent. Mycoplasma Pneumoniae infection is another important cause of EM, particularly in children. Laboratory findings are not specific and clinical finding are necessary for diagnosis. A skin biopsy should be performed when the diagnosis is unclear. CASE REPORT: 14 year old male came to our attention for the appearance of cutaneous lesions, accompanied by high fever. The skin appeared almost entirely affected by roundish, sharp, erythematous lesions, some of these with evident ‘coccard’ sign, other ecchymotic with hemorrhagic nuance, confluent to the trunk in large patches. No recent history of infections or drugs. Laboratory findings showed a neutrophilia (N 8810/mcl) and eosinophilia (E 980/mcl) and high inflammatory indices (PCR 4.75 mg/dl, ferritin 517 kg/ml). Peripheral smear, autoimmunity, virological and bacterial screening and instrumental examinations were negative. On the third day of admission, he performed a nasal swab (Multiplex) due to the appearance of rhinorrhea and cough. It was positive for Human Metapenumovirus (HM). On the seventh day, there was a new poussé of erythematous, itchy, coccard element on the whole body surface. He was treated with antihistaminic, steroid and antibiotic therapy with gradual rash regression, desquamation of skin lesions and defervescence. In literature it is known that HM is a common cause of upper respiratory tract infection in children. However, no further cases are reported regarding the possible relationship between skin lesions and HM. In our case the only laboratory finding associate to the EM was a positive RT-PCR for HM. This observation could lead to further scientific evaluations

WHEN A VIRUS HAS DIFFERENT FACES

Measles is a highly contagious viral illness, characterized by fever, malaise, cough, coryza and conjunctivitis, followed by maculopapular exanthema, which spreads cephalocaudally and centrifugally. Measles, mumps, rubella (MMR) vaccination has led to the interruption of measles virus transmission and gives protection to unvaccinated individuals via herd immunity. The morbilliform exanthema can be found in various conditions, including infectious mononucleosis. It is characterized by fever, pharyngitis, lymphadenopathy and a generalized maculopapular, urtical or petechial rash occasionally can be present, especially after administration of beta-lactams. CASE REPORT: 17 months old male was admitted in our pediatric department for the appearance, 4 days earlier, of rash and fever (T 38,8°C). The exanthema consisted of an erythematous, maculopapular, blanching rash, which began on the face and progressed to the truck and extremities involving the palms and soles. In some areas it showed confluent and hemorrhagic features. The physical examination showed the presence of laterocervical lymphadenopathy, nonpurulent conjunctivitis and pharyngitis. About 10 days earlier it was administered antibiotic therapy with Amoxicillin for a fever associated with malaise, cough and coryza. The child had no history of allergies and the MMR vaccine was repeatedly delayed and eventually not carried out for multiple episodes of respiratory infections. The laboratory tests showed leucocitosis with a normal differential count, mild elevation of transaminases, elevation of inflammatory markers and LDH; the morphological evaluation of the peripheral smear showed some activated lymphomonocitoid cells. Given the rash characteristics and the strong suspicion of measles, the patient was located in isolation and infectivological tests were performed (TORCH, Monotest, Respiratory Multiplex PCR panel and a serology for measles). They all came back negative except for the anti VCA IgM for EBV infection. The patient was treated with IV fluids and antipyretics. Antibiotic therapy was administered in order to prevent bacterial superinfections. After 72 hours the rash started to darken and then to gradually fade. The patient was dismissed with the diagnosis of maculopapular exanthema in mononucleosis infection. Clinical manifestations of infectious mononucleosis can be similar to those of measles and, especially in unvaccinated patients, can sometimes be confused with it. Maculopapular exanthema can be found in various conditions, such as common viral or bacterial infections, IgA vasculitis, Kawasaki disease or drug eruption. For this reason, it is important to consider mononucleosis in the differential diagnosis of measles, especially in case of hemorrhagic and infiltrated rash, not much described in the literatur