SAEM Clinical Images Series: Infantile Enigma

rash

A previously healthy 4-week-old born full-term presented to the emergency department with possible umbilical drainage and a new onset rash in the left lower abdominal region. The patient had an uncomplicated newborn stay with a mother with negative maternal serologies other than GBS positive, which was appropriately treated intrapartum. The patient had been gaining weight well without fevers or sick symptoms. Parents reported that their pediatrician had seen the patient earlier in the day for a routine check-up. Notably, a “cream” was applied to a small remnant of the umbilical cord that was still present. The parents noted that this abdominal rash was not present and only discovered during this evening’s diaper change. Parents had potentially accounted for this rash as a seat belt that may have been placed too tight.

General: Well-appearing neonate in no acute distress.

HEENT: Atraumatic, appropriate fontanelle. No abnormal bruising. No frenulum tears. No scalp hematomas.

Cardiac: Regular rate and rhythm. No auscultated murmur.

Pulmonary: Clear lung sounds bilaterally.

Abdomen: Soft, non-tender, non-distended. Umbilicus has homogenous darkening without evidence of fluctuance, erythema, or drainage. The left lower abdomen has a linear homogenously darkened macular rash without vesicular lesions, minimally erythematous, and no fluctuance.

Genitourinary: Phenotypic external male genitalia without rash.

Integumentary: Otherwise, no abnormal bruising or rash was noted.

None

To our knowledge, the “cream” that was applied to the umbilicus was silver nitrate, a joint compound used to cauterize umbilical granulomas. This compound is made of silver and potassium nitrate, activated when mixed with moisture. Its application may have unfavorable events if misapplied, and if applied to healthy skin, it may result in burns. We suspect this linear rash to be an accidental contact swipe of a silver nitrate stick. This patient was treated as a mild chemical burn – bacitracin applied along with a non-stick dressing and bandages with outpatient follow-up. In our evaluation of this patient, we considered early infection source or non-accidental trauma but did not pursue additional workup given this clinical history and presentation.

Take-Home Points

  • Silver nitrate sticks can be used to stop localized bleeding in the emergency department setting. It is important to be cautious when handling and applying as it may cause unwanted burns.

  • In the evaluation of the newborn rash, underlying severe infection or non-accidental trauma must be considered in the differential.

  • Sanyaolu L N, Javed M, Wilson-Jones N. A baby with a discharging umbilical lesion BMJ 2016; 355:i5587 doi:10.1136/bmj.i5587

  • Majjiga VS, Kumaresan P, Glass EJ. Silver nitrate burns following umbilical granuloma treatment. Arch Dis Child. 2005 Jul;90(7):674. doi: 10.1136/ adc.2004.067918. PMID: 15970607; PMCID: PMC1720504

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.