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CASE REPORT
Year : 2014  |  Volume : 15  |  Issue : 3  |  Page : 147-149

Annular erythema of infancy: A diagnostic challenge


1 Department of Dermatology, STD and Leprosy, Burdwan Medical College, Burdwan, India
2 Department of Dermatology, Bangalore Medical College and Research Institute, Bangalore, India
3 Department of Pediatrics, Dr. B. C. Roy Post Graduate institute of Paediatric Sciences, Kolkata West Bengal, India

Date of Web Publication30-Oct-2014

Correspondence Address:
Abhijit Saha
46/4, Swarnamoyee Road, P.O: Berhampore, Murshidabad, 742 101, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.143678

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  Abstract 

Annular erythemas in infancy are uncommon to rare in occurreance. Erythema migrans is the most common variety to be reported amidst the younger age group. This group of conditions poses a diagnostic challenge to the physician as the differentials can range from a benign annular erythema of infancy with good prognosis and no long-term defects to neonatal lupus erythematosus (NLE) having a bad prognosis with increased morbidity and mortality. We report a case of annular erythema of infancy in a 5 day old male infant to emphasize that in spite of the history of spontaneous abortions in the mother, which pointed towards a more grave diagnosis of NLE, benign conditions like annular erythema of infancy needs to be kept in mind.

Keywords: Annular erythema of infancy, benign, maternal history of abortions


How to cite this article:
Saha A, Seth J, Mukherjee S, Basu S. Annular erythema of infancy: A diagnostic challenge. Indian J Paediatr Dermatol 2014;15:147-9

How to cite this URL:
Saha A, Seth J, Mukherjee S, Basu S. Annular erythema of infancy: A diagnostic challenge. Indian J Paediatr Dermatol [serial online] 2014 [cited 2020 Feb 17];15:147-9. Available from: http://www.ijpd.in/text.asp?2014/15/3/147/143678


  Introduction Top


Annular erythema is a broad term used to describe lesions which are annular, circinate, serpiginous, arcuate or coin like. The annular erythemas have a tendency to slowly evolve centrifugally or can remain fixed depending on its etiology. In dermatology the classical annular erythemas described are erythema gyratum repens, erythema annulare centrifugum, and erythema marginatum and erythema chronicum migrans. [1] In addition to this, other entity which has been added is annular erythema of infancy. This is an idiopathic, self-resolving, uncommon condition. Various causes of annular erythematous lesions in the first few weeks of life include neonatal lupus erythematosus (NLE), erythema annulare centrifugum, annular erythema of infancy, familial annular erythema, tinea corporis, acute urticarial and erythema atrophicans transiens neonatal. [2],[3],[4],[5],[6],[7]


  Case report Top


A 5 day old male child born at term, of nonconsanguineous marriage was admitted with skin lesions all over body predominantly over the trunk and face since the 2 nd day of life.

The mother was a multigravida with history of 2 abortions at 12 and 16 weeks in the past, however the causes for which were not evaluated. She was healthy and asymptomatic. There was no history suggestive of any connective tissue disease.

Clinical examination revealed an alert, euglycemic infant weighing 3.2 kg with good reflexes. Cutaneous examination revealed multiple brightly erythematous, annular plaques distributed over the chest, back, arms and thighs including the face [Figure 1]. The expanding borders of the lesions were palpable, and there was no detectable scaling or atrophy [Figure 2] and [Figure 3]. Individual lesions were persistent and enlarging since their appearance.
Figure 1: Erythematous, annular plaques distributed over the chest, back, arms and thighs and face

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Considering the clinical examination and history a provisional diagnosis of the annular variant of NLE was considered and investigations were carried out.

Routine blood investigations in the child revealed a raised total leucocyte count with the blood culture showing growth of Klebsiella organisms. The mother was evaluated for Antiphospholipid antibody syndrome and connective tissue disease which were negative. The Venereal Disease Research Laboratory test done on mother and baby was negative. Anti Ro-SSA/La-SSB antibodies were also negative in the mother and child. Cardiac screening of the child did not reveal any heart blocks. A biopsy of the skin lesion was done, revealed a superficial and deep perivascular lympho-histiocytic inflammatory infiltrate. A skin scraping done from the lesions was negative for fungal elements.
Figure 2: Close-up view of annular erythema

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Figure 3: Close-up view of annular erythema

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While inward many lesions underwent spontaneous resolution. The diagnosis was revised as annular erythema of infancy, and the child was treated with Injectable piperacillin and amikacin in view of the gram negative septicemia and was discharged in stable condition with topical application of emollients alone.


  Discussion Top


Annular erythemas in infancy pose a diagnostic challenge and dilemma to the clinician. They range from benign self-resolving conditions like annular erythema of infancy to life-threatening and poor outcome conditions like NLE thereby making the diagnosis of the condition imperative. Clinically, annular erythemas of infancy can be distinguished by mode of onset, evolution, distribution and morphology of skin lesions, associated features and family history.

In view of some of the authors, an anti Ro anti La antibody test should be performed in all cases of annular skin lesions in infancy along with cardiac screening with electrocardiogram to avoid missing out on cases of NLE. [8]

Another case reported in India shows the importance of a KOH examination of the scales in an infant, which turned the diagnosis to tinea corporis from NLE thus implying the necessity to rule out infections in an infant with annular lesions. [7]

Annular erythema of infancy is a relatively recently described entity in 1981 by Peterson and Jarratt. [9] It is a benign condition characterized by the cyclical eruption of annular, erythematous lesions with minimal scaling which resolve spontaneously in a few weeks without any atrophy or pigmentary disturbances. This condition although classified under the transient annular erythemas, has shown to have relapsing courses up to 1-year of age. There have been reports of the condition being persistent until 1-year of age followed by spontaneous resolution with no sequelae. It has been hypothesized that annular erythema of infancy may be a hypersensitivity reaction to an unidentified antigen, although the etiology largely remains unknown.

The other causes of annular erythemas of infancy need to be excluded by investigations like KOH examination of the scales, anti-Ro/La antibody titers, histopathology and a cardiac screening of the infant.

Treatment of the condition remains simple with reassurance to the family and mere emollients as it is a condition with no harmful outcomes.

Annular erythema in a neonate poses a challenge to the diagnostic skills of the clinician with a dilemma as to which ones require treatment and which don't. When we worked up the case, we learnt that in spite of the history of spontaneous abortions in the mother, which pointed towards a more grave diagnosis of, benign conditions like annular erythema of infancy needs to be kept in mind.

 
  References Top

1.España A. Figurate erythema. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Bolognia Dermatology. 2 nd ed. USA: Mosby Elsevier; 2008. p. 277-86.  Back to cited text no. 1
    
2.Horii KA, Nopper AJ. Annular erythemas. In: Harper J, Oranje A, Prose N, editors. Textbook of Pediatric Dermatology. 2 nd ed., Vol 1. Oxford: Blackwell Science; 2006. p. 718-25.  Back to cited text no. 2
    
3.Tamayo-Sanchez L, Ruiz-Maldonado R, Laterza A. Acute annular urticaria in infants and children. Pediatr Dermatol 1997;14:231-4.  Back to cited text no. 3
    
4.Fried R, Litt JZ, Schonberg IL. Erythema annulare centrifugum (Darier) in a newborn infant. J Pediatr 1957;50:66-7.  Back to cited text no. 4
    
5.Puig L, Moreno A, Alomar A, de Moragas JM. Erythema gyratum atrophicans transiens neonatale: A variant of cutaneous neonatal lupus erythematosus. Pediatr Dermatol 1988;5:112-6.  Back to cited text no. 5
    
6.Beare JM, Froggatt P, Jones JH, Neill DW. Familial annular erythema. An apparently new dominant mutation. Br J Dermatol 1966;78:59-68.  Back to cited text no. 6
    
7.Palit A, Inamadar AC. Annular, erythematous skin lesions in a neonate. Indian Dermatol Online J 2012;3:45-7.  Back to cited text no. 7
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8.Kettler AH, Stone MS, Bruce S, Tschen JA. Annular eruptions of infancy and neonatal lupus erythematosus. Arch Dermatol 1987;123:29.  Back to cited text no. 8
    
9.Peterson AO Jr, Jarratt M. Annular erythema of infancy. Arch Dermatol 1981;117:145-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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