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CASE REPORT
Year : 2014  |  Volume : 15  |  Issue : 3  |  Page : 117-119

Erythema multiforme due to parainfluenza virus in a newborn: A case report and review of the literature


Department of Pediatrics, Division of Neonatology, Ankara University, School of Medicine, Ankara, Turkey

Date of Web Publication30-Oct-2014

Correspondence Address:
Dilek Kahvecioglu
Department of Pediatrics, Division of Neonatology, Ankara University School of Medicine, Mamak, Ankara - 06260
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.143663

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  Abstract 

Erythema multiforme is an acute, self-limited skin disorder that is considered to be a hypersensitivity reaction associated with certain infections, medications, and many other reasons. Parainfluenza virus infection may be an etiologic factor for this uncommon entity. Here we report a newborn with EM associated with parainfluenza virus (PIV) infection and a review of the literature on neonatal EM.

Keywords: Erythema multiforme, newborn, parainfluenza virus


How to cite this article:
Kahvecioglu D, Erdeve O, Atasay B, Yildiz D. Erythema multiforme due to parainfluenza virus in a newborn: A case report and review of the literature. Indian J Paediatr Dermatol 2014;15:117-9

How to cite this URL:
Kahvecioglu D, Erdeve O, Atasay B, Yildiz D. Erythema multiforme due to parainfluenza virus in a newborn: A case report and review of the literature. Indian J Paediatr Dermatol [serial online] 2014 [cited 2020 Sep 20];15:117-9. Available from: http://www.ijpd.in/text.asp?2014/15/3/117/143663


  Introduction Top


Erythema multiforme (EM) is an acute, self-limited skin disorder that is considered to be a hypersensitivity reaction associated with certain infections, medications, and many other reasons. It is characterized by distinctive target lesions generally on the face and extremities. Patients may present with erythematous annular macules, papules, patches, plaques, or wheals, but the characteristic clinical feature of EM is the target lesion, which has three distinct zones: Acentral dusky disk surrounded by a clear ring and an outer erythematous halo. EM occurs at any age, but mostly in adoIescent and young adults. [1],[2] It is a rare condition in childhood and especially in infancy, and only few cases in neonatal period have been reported. [1],[3],[4],[5],[6],[7],[8],[9],[10],[11] Here we report a newborn with EM associated with parainfluenza virus (PIV) infection and a review of the literature on neonatal EM.


  Case report Top


A female neonate with erythematous annular plaques on her body was brought to the hospital. She was born to a 27-year-old gravida 2, para 2 mother via cesarean section. The pregnancy and birth were uneventful. On the 17 th postnatal day of life, she was admitted to our neonatal intensive care unit for respiratory insufficiency. During her initial hospitalization, nasal secretion PCR revealed respiratory syncytial virus (RSV)-type 2, adenovirus and PIV type 3 as respiratory pathogens. She had to be entubated and followed on mechanical ventilation for 7 days and was discharged on the 12 th day of hospitalization. Ten days after discharge her mother recognized the erythematous patches and plaques which became annular shaped within 2 days and spread to her trunk and four extremities. She had no fever or no other associated symptoms.

Annular patchs and plaques on her face, trunk, legs and arms were recorded on physical examination. The lesions had central dusky center, surrounded by pale halo and erythematous border [Figure 1] and [Figure 2]. There was no mucosal lesion and the rest of her systemic examination was unremarkable. Complete blood count, acute phase reactants, serum biochemistry and urine analysis revealed normal results. Serological evalution for the possible etiology including toxoplasma, rubella, cytomegalovirus, rubeola, ebstein barr virus, RSV and herpes simplex virus type 1-2 were negative. Four days after her initial outpatient visit, she was rehospitalized for bronchiolitis and viral serology from nasal secretion revealed parainfluenza type 3 virus. A skin biopsy was performed from the target lesion on her trunk which showed minimal perivascular dermatitis. Depending on the characteristic skin lesions; the patient was diagnosed as EM. Local hydrocortisone acetate therapy was applied on her lesions for 5 days, which resulted in fading of lesions. All lesions disappeared within 2 months on her follow up.
Figure 1: Frequent target lesions on patient's trunk

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Figure 2: Erythemataous rash on application. These lesions responded to topical steroid within 5 days

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  Discussion Top


EM is an acute, self-limited, immune-mediated mucocutaneus condition of with an estimated frequency of approximately 1.2-6 cases per million individuals per year. [2] Only few cases in the neonatal period have been reported in the literature. [Table 1] shows newborn cases with EM in relation to their etiologies. To the best of our knowledge, a neonatal EM associated with PIV has not been reported before.
Table 1: Newborn cases reported to have EM in the literature


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The pathophysiology of EM is still not completely understood, but cell-mediated immunity appears to be responsible for the destruction of epithelial cells. Many triggering factors such as infections such as herpes simplex virus, mycoplasma pneumonia, hepatitis viruses, toxoplasma, influenza and candida, vaccinations, drugs, food allergy and malignancies have been reported as etiologic factors in association with EM in newborns. [1],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] However, when all reported cases are evaluated vaccination (HBV, BCG, DPT) and infections seem to be the major causes.

Human PIV belongs to the order Mononegavirales, the family Paramyxoviridae, and the subfamily Paramyxovirinae. They currently comprise five serotypes-PIV-1, PIV-2, PIV-3, PIV-4a, and PIV-4b. PIVs primarily affect young children, in whom the pathogenic spectrum includes upper and lower respiratory tract infections. They are responsible for 30-40% of all acute respiratory tract infections in infants and children. These conditions include common cold with fever, laryngotracheobronchitis (croup), bronchiolitis, and pneumonia. However, they rarely affect skin. Hsieh et al., reported that only 4.9% of the infected 206 children with PIV had skin rashes. [13] On the other hand, Yang et al. described only one case of possible PIV-related EM in their series. [14] We demonstrated PIV type 3 in our patient which has not been reported in association with EM in neonatal period. Abscence of immunologic markers in addition to characteristic findings of neonatal lupus, no history of medication and being fed with exclusive breastmilk led us to rule out neonatal lupus, drug reaction and food allergy in differential diagnosis, respectively.

Treatment of EM depends on the causes of the illness and eliminating the underlying factors. The use of corticosteroids has generated controversy, they were generally used in severe EM cases. Topical corticosteroid can be used for local symptomatic improvement as in our patient. [15] We used hydrocortisone acetate for only 5 days at the initial phase of the illness which resulted in fading of the lesions, and no further treatment was required for spontaneous resolution on follow-up.

In conclusion, EM is an extremely rare condition in the neonatal period and PIV may be an etiologic factor for this uncommon entity. We suggest that follow-up of such patients without major medications may result in spontaneous resolution.

 
  References Top

1.Nanda S, Pandhi D, Reddy BS. Erythema multiforme in a 9-day-old neonate. Pediatr Dermatol 2003;20:454-5.  Back to cited text no. 1
[PUBMED]    
2.Roujeau JC. Erythema multiforme. In: Wolff K, Goldsmith L, editors. Fitzpatrick′s Dermatology in General Medicine, 7 th ed. New York: McGraw-Hill; 2008. p. 343-9.  Back to cited text no. 2
    
3.Torella A, Monera M, Prada I, Celma M, Zambrano A. Erythema multiforme in a neonate. J Am Acad Dermatol 2003;48:78-9.  Back to cited text no. 3
    
4.Ang-Tiu CU, Nicolas ME. Erythema Multiforme in a 25-Day Old Neonate. Pediatr Dermatol 2012;30:e118-20.  Back to cited text no. 4
    
5.Kaur S, Handa S. Erythema multiforme following vaccination in an infant. Indian J Dermatol Venereol Leprol 2008;74:251-3.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.Kortring HC, Vieluf D. Erythema multiforme and dermatitis seborroides infantum as concominant id-reactions to widespread candidiosis in a suckling. Mycoses 1991;34:415-7.  Back to cited text no. 6
    
7.Ashkenazi S, Metzker A, Rachmel A, Nitzan M. Erythema multiforme as a single manifestation of cow′s milk intolerance. Acta Paediatr 1992;81:729-30.  Back to cited text no. 7
[PUBMED]    
8.Cieza-Díaz DE, Campos-Domínguez M, Santos-Sebastián Mdel M, Fernández-Antón Martínez Mdel C, Ceballos-Rodríguez Mdel C, Navarro-Gómez ML, et al. Erythema multiforme in a newborn associated with acute acquired cytomegalovirus infection. Pediatr Dermatol 2012;30:e161-3.  Back to cited text no. 8
    
9.Wu CC, Tsai CN, Wong WR, Hong HS, Chuang YH. Early congenital syphilis and erythema multiforme-like bullous targetoid lesions in a 1-day-old newborn: Detection of Treponema pallidum genomic DNA from the targetoid plaqueus ingnested polymerase chain reaction. J Am Acad Dermatol 2006;55:11-5.  Back to cited text no. 9
    
10.Cho YJ, Huh SY, Hong JS, Jung JY, Suh DH. Neonatal erythema multiforme: A case report. Ann Dermatol 2011;23:382-5.  Back to cited text no. 10
    
11.Dikland WJ, Oranje AP, Stolz E, van Joost T. Erythema multiforme in childhood and early infancy. Pediatr Dermatol 1986;3:135-9.  Back to cited text no. 11
[PUBMED]    
12.Henrickson KJ. Parainfluenza viruses. Clin Microbiol Rev 2003;16:242-64.  Back to cited text no. 12
[PUBMED]    
13.Hsieh YJ, Chin H, Chiu NC, Huang FY. Hospitalized pediatric parainfluenza virus infections in a medical center. J Microbiol Immunol Infect 2010;43:360-5.  Back to cited text no. 13
    
14.Yang TY, Lu CY, Kao CL, Chen RT, Ho YH, Yang SC, et al. Clinical manifestations of parainfluenza infection in children. Microbiol Immunol Infect 2003;36:270-4.  Back to cited text no. 14
    
15.Yeung AK, Goldman RD. Use of steroids for erythema multiforme in children. Can Fam Physician 2005;51:1481-3.  Back to cited text no. 15
    


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