Necrotizing Anogenital Ulcer in a Healthy 8-Month-Old Male

Abstract

A healthy 8-month-old male infant was admitted for management of a rapidly progressive, painful anogenital ulcer. The lesion had developed acutely over 48 hours, starting as symmetric pink patches leading to pustules, erosions, and ulceration. Associated symptoms included generalized fatigue, but no fevers, chills, or other systemic symptoms. The child's parents denied any new topical exposures or medications. The child was born via vaginal delivery at full term. Pregnancy was complicated by gestational diabetes. The child had no major medical issues and met all developmental milestones. There was no relevant family medical history. Broad-spectrum intravenous antibiotics were initiated on admission. Dermatology was consulted prior to scheduled debridement and skin grafting.Physical examination revealed a well-appearing infant with normal vital signs. Extending from the gluteal cleft to just medial to the scrotum, there was a symmetric, well-defined ulcer withacribriformbase,centralnecrosis,androlled,pink-to-violaceous,underminedborder(Figure , A). Initial laboratory workup was significant for leukocytosis (22 000/mm 3 ) and thrombocytosis (764 000/mm 3 ). Serum zinc and alkaline phosphatase were within normal limits. A punch biopsy of the edge of the ulcer was obtained and stained with hematoxylin-eosin (Figure , B and C). Microbial stains were negative. Tissue cultures for anaerobic and/or aerobic, mycobacterial, and fungal organisms were all negative, though wound cultures grew Escherichia coli, Klebsiella oxytoca, and Enterococcus faecalis. Viral cultures were negative.