Nappy rash is a common problem in infants due to their thinner skin, wetness, heat and friction under cloth nappy, fecal enzymes and alkaline urine. The disposable diapers containing Super Absorbent Material (SAM) reduce the incidence of nappy rash. SAM quickly absorbs urine and keeps the skin dry. Also disposable diapers prevent fecal contamination by absorbing the urine and containing stools.
A 15-year-old female from Uttar Pradesh, India presented to pediatric emergency unit with bilateral joint pain, breathlessness, multiple necrotic skin lesions, and a six-month history of intermittent fever. On examination, she had multiple maculopapular lesions over her whole body and hepatosplenomegaly. Earlier investigations revealed pancytopenia. We considered a clinical diagnosis of lupus. Complete blood count showed hemoglobin 8.5 g/dL, total leucocyte count was 2,220/L, platelets were 108,000/L, and the absolute neutrophil count was 1,887/L. The peripheral blood smear revealed occasional monocytic-macrophage lineage cells with engulfed yeast-like forms of Histoplasma capsulatum (A, MGG, ×100; B, ×40). Bone marrow biopsy showed increased plasma cells and histiocytes with many intracellular and extracellular forms of the fungus (arrow) (C, H&E stain, ×40). Occasional loose clusters of epithelioid histiocytes and foreign body giant cells were noted. Inset (D, ×40) shows fungus on the Gomori methenamine silver stain. The fungus was obtained from skin scraping. She was immediately started on amphotericin B and itraconazole. The immunological workup showed elevated IgG and a normal CD4:CD8 ratio. The workup for chronic granulomatous disease and HIV was negative. Despite dual antifungal therapy she succumbed to disseminated disease. Finding circulating fungal forms is a rare ominous event, especially in immunocompetent hosts.
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