Fetal and Pediatric Pathology, Early Online:1–5, 2015 C Informa Healthcare USA, Inc. Copyright ISSN: 1551-3815 print / 1551-3823 online DOI: 10.3109/15513815.2015.1044142
ORIGINAL ARTICLE
Fetal Pediatr Pathol Downloaded from informahealthcare.com by University of Otago on 07/27/15 For personal use only.
Livedo Reticularis: A Presenting Sign of Escherichia Coli Sepsis in a Newborn ´ Lopes,1 Valerie ´ Champion,2 Stephane ´ Anne-Aurelie Bonacorsi,3 2 and Delphine Mitanchez 1
Facult´e de M´edecine Pierre et Marie Curie, Paris, France; 2 Service de N´eonatologie, Assistance Publique–Hˆopitaux de Paris, Hˆopital Armand Trousseau, Paris, France; 3 Service de Microbiologie, Assistance Publique–Hˆopitaux de Paris, Hˆopital Robert Debr´e, Paris, France
Livedo reticularis is a red cutaneous netlike pattern that is caused by abnormalities of the microvascularization and can be associated with many other potential systemic etiologies. We describe a case of a newborn that presented with livedo reticularis on his first day of life without any obvious systemic signs. The livedo reticularis was associated with Escherichia Coli K1 meningitis as revealed by laboratory tests. Clinical infectious signs developed a few hours later. Despite appropriate antibiotics therapy, he died on his second day because of sepsis and disseminated intravascular coagulation. Cerebrospinal fluid culture, blood culture, and culture of samples from trachea showed the presence of Escherichia Coli serotype K1 with many virulence determinants. Conclusion: In newborn, livedo reticularis must not be considered as physiological, but as a potential sign of unknown severe bacterial infection. Thus, the presence of livedo reticularis must require urgent laboratory tests. Keywords: Livedo reticularis, Escherichia Coli K1, meningitis, sepsis, newborn
INTRODUCTION Livedo reticularis (LR) is a reddish-violaceous netlike pattern on the skin that blanches in diascopy. It first affects the lower extremities of the limbs and can later expand into any part of the body [1, 2]. LR is caused by abnormalities of the cutaneous microvascularization: it represents increased visibility of the venous plexus. Physiologically, it is caused by a decreased or an interruption of blood flow in the dermal arteries or an increased resistance to venous outflow. The potential causes are spasm, inflammation, or vascular obstruction. If a skin biopsy is performed, it would show an inflammatory lesion or an obstruction of the vessel (by thrombosis, emboli,. . .) [2]. Thus, LR is subdivided into four types: physiological, primary, idiopathic, or associated with varying systemic etiologies including drugs effects, autoimmune or endocrine disorder, neurological disease, cholesterol or septic emboli, infectious diseases, neoplasia, or newborn from mother with these diseases [1, 2]. If the diagnosis of LR is made easy, the difference between subtypes is subtle. The first type, physiologic LR or cutis marmorata, is common on newborn, appears with cold exposure and Received 08 April 2015; revised 16 April 2015; accepted 20 April 2015. Address correspondence to Anne-Aur´elie Lopes, Facult´e de M´edecine Pierre et Marie Curie, 15 Rue de l’Ecole de M´edecine, Paris 75006, France. E-mail: [email protected]
Fetal Pediatr Pathol Downloaded from informahealthcare.com by University of Otago on 07/27/15 For personal use only.
A.-A. Lopes et al.
Figure 1. Reticulated violaceous livedo that blanched on diascopy and was present on the four limbs.
resolves with warming. The second type, primary LR is intermittent, caused by spontaneous and recurrent vasospasm. The third type, idiopathic LR, is persistent, without a known cause. They are diagnoses of exclusion. The last subtype is LR associated with varying systemic diseases with specific signs and laboratory tests to confirm the diagnosis. We report a case of a newborn who presented LR as a first sign of Escherichia Coli (E. coli) K1 sepsis. CASE REPORT A newborn boy was born at term, after 10 hours of rupture of membranes. No bacteriological culture was performed in the absence of infectious context. The mother was primigravida, with insemination of donor sperm. There was no significant past medical history or noted systemic diseases from the mother or her family. The history of the donor is, however, unknown.
Fetal and Pediatric Pathology
Fetal Pediatr Pathol Downloaded from informahealthcare.com by University of Otago on 07/27/15 For personal use only.
Livedo Reticularis and Escherichia Coli in Newborn
The mother was admitted at 37 weeks and 5 days and delivered one day later. On the admission day, vaginal swab was done and called negative. Two hours after delivery, given maternal fever of 38.6◦ C, laboratory tests revealed: white cell count of 22 × 109 /L with neutrophils count of 19.96 × 109 /L and C-reactive protein level of 26 mg/L. She received antibiotics therapy with amoxicillin-clavulanic acid. At 15 hours after delivery, the nurse discovered ‘generalized mottlings’ on the newborn. The examination noticed a pink, tonic and clinically reassuring infant without any hemodynamic abnormality (heart rate of 175 bpm, peripheral pulses well perceived, warm extremities, capillary refill time (CRT)
ORIGINAL ARTICLE
Fetal Pediatr Pathol Downloaded from informahealthcare.com by University of Otago on 07/27/15 For personal use only.
Livedo Reticularis: A Presenting Sign of Escherichia Coli Sepsis in a Newborn ´ Lopes,1 Valerie ´ Champion,2 Stephane ´ Anne-Aurelie Bonacorsi,3 2 and Delphine Mitanchez 1
Facult´e de M´edecine Pierre et Marie Curie, Paris, France; 2 Service de N´eonatologie, Assistance Publique–Hˆopitaux de Paris, Hˆopital Armand Trousseau, Paris, France; 3 Service de Microbiologie, Assistance Publique–Hˆopitaux de Paris, Hˆopital Robert Debr´e, Paris, France
Livedo reticularis is a red cutaneous netlike pattern that is caused by abnormalities of the microvascularization and can be associated with many other potential systemic etiologies. We describe a case of a newborn that presented with livedo reticularis on his first day of life without any obvious systemic signs. The livedo reticularis was associated with Escherichia Coli K1 meningitis as revealed by laboratory tests. Clinical infectious signs developed a few hours later. Despite appropriate antibiotics therapy, he died on his second day because of sepsis and disseminated intravascular coagulation. Cerebrospinal fluid culture, blood culture, and culture of samples from trachea showed the presence of Escherichia Coli serotype K1 with many virulence determinants. Conclusion: In newborn, livedo reticularis must not be considered as physiological, but as a potential sign of unknown severe bacterial infection. Thus, the presence of livedo reticularis must require urgent laboratory tests. Keywords: Livedo reticularis, Escherichia Coli K1, meningitis, sepsis, newborn
INTRODUCTION Livedo reticularis (LR) is a reddish-violaceous netlike pattern on the skin that blanches in diascopy. It first affects the lower extremities of the limbs and can later expand into any part of the body [1, 2]. LR is caused by abnormalities of the cutaneous microvascularization: it represents increased visibility of the venous plexus. Physiologically, it is caused by a decreased or an interruption of blood flow in the dermal arteries or an increased resistance to venous outflow. The potential causes are spasm, inflammation, or vascular obstruction. If a skin biopsy is performed, it would show an inflammatory lesion or an obstruction of the vessel (by thrombosis, emboli,. . .) [2]. Thus, LR is subdivided into four types: physiological, primary, idiopathic, or associated with varying systemic etiologies including drugs effects, autoimmune or endocrine disorder, neurological disease, cholesterol or septic emboli, infectious diseases, neoplasia, or newborn from mother with these diseases [1, 2]. If the diagnosis of LR is made easy, the difference between subtypes is subtle. The first type, physiologic LR or cutis marmorata, is common on newborn, appears with cold exposure and Received 08 April 2015; revised 16 April 2015; accepted 20 April 2015. Address correspondence to Anne-Aur´elie Lopes, Facult´e de M´edecine Pierre et Marie Curie, 15 Rue de l’Ecole de M´edecine, Paris 75006, France. E-mail: [email protected]
Fetal Pediatr Pathol Downloaded from informahealthcare.com by University of Otago on 07/27/15 For personal use only.
A.-A. Lopes et al.
Figure 1. Reticulated violaceous livedo that blanched on diascopy and was present on the four limbs.
resolves with warming. The second type, primary LR is intermittent, caused by spontaneous and recurrent vasospasm. The third type, idiopathic LR, is persistent, without a known cause. They are diagnoses of exclusion. The last subtype is LR associated with varying systemic diseases with specific signs and laboratory tests to confirm the diagnosis. We report a case of a newborn who presented LR as a first sign of Escherichia Coli (E. coli) K1 sepsis. CASE REPORT A newborn boy was born at term, after 10 hours of rupture of membranes. No bacteriological culture was performed in the absence of infectious context. The mother was primigravida, with insemination of donor sperm. There was no significant past medical history or noted systemic diseases from the mother or her family. The history of the donor is, however, unknown.
Fetal and Pediatric Pathology
Fetal Pediatr Pathol Downloaded from informahealthcare.com by University of Otago on 07/27/15 For personal use only.
Livedo Reticularis and Escherichia Coli in Newborn
The mother was admitted at 37 weeks and 5 days and delivered one day later. On the admission day, vaginal swab was done and called negative. Two hours after delivery, given maternal fever of 38.6◦ C, laboratory tests revealed: white cell count of 22 × 109 /L with neutrophils count of 19.96 × 109 /L and C-reactive protein level of 26 mg/L. She received antibiotics therapy with amoxicillin-clavulanic acid. At 15 hours after delivery, the nurse discovered ‘generalized mottlings’ on the newborn. The examination noticed a pink, tonic and clinically reassuring infant without any hemodynamic abnormality (heart rate of 175 bpm, peripheral pulses well perceived, warm extremities, capillary refill time (CRT)
