Another Mosquito Bite...In the Middle of Winter?

Case Study

Chief Complaint

The patient, E.M., has recurrent "mosquito bites."

History of Present Illness

E.M. is a previously healthy 2-year-old girl who had a diaper rash 4 months prior to referral to the Infectious Diseases service. At that time, what appeared to be a "mosquito bite" also developed on her buttock. E.M.'s mother reported that her daughter's "mosquito bite" began as a small red bump resembling a pimple and quickly became a firm, beefy-red, extremely painful lesion. E.M. was unable to sit because of the discomfort from this lesion on her buttock. The morning after the onset, she was taken to her primary care provider's office and subsequently was admitted to the local hospital for an incision and drainage procedure of the lesion. E.M. was discharged from the hospital the following day with an oral prescription for some type of antibiotic (the mother does not remember the name of the "pink medicine") and Nystatin cream to be placed in the groin region.

Approximately 2 weeks later, E.M. had a recurrence of "mosquito bites" in her groin area. Since that time, she has continued to have recurrent "mosquito bites" on her upper thighs and groin area. Some of these lesions discharge white pus and others resolve spontaneously within about 1 week's time. The lesions are not itchy but are very painful. When the lesions heal, they scar. E.M. has had multiple visits to her primary care provider's office and has taken multiple courses of oral antibiotics for these "mosquito bites." The family does not think any of the antibiotics have helped. The last course of antibiotics was given approximately 2 weeks prior to referral, and E.M. currently has a new "mosquito bite" that began 1 day before her appointment with Infectious Diseases.

Medical History

E.M. was born 1 week early by normal spontaneous vaginal delivery. She was discharged at 2 days of life. She was hospitalized at age 20 months for an incision and drainage procedure on buttock lesion, which resulted in a scar. She has taken multiple antibiotics for "mosquito bites." No other surgeries or hospitalizations were reported, and she has no known allergies. Immunizations are up to date. E.M. is not taking any current medications, and she is on a regular diet.

Personal/Social History

E.M. lives with her parents. There are no pets in the home. No international travel was reported. E.M. does not attend day care or school; she is cared for by her mother during the day. Her mother is a homemaker, and her father is a nurse in a local hospital. There are no signs of mosquitos or ticks at home. E.M. has met all developmental milestones to date.

Family History

E.M.'s mother reports that she has had similar skin lesions since her gastric bypass surgery 1 year ago. Her lesions are located throughout her body and require drainage and/or oral antibiotics. She also reports that she required intravenous antibiotics for a week for a lesion she had 6 months ago.

Review of Systems

E.M. has low-grade fevers (100°F) at the onset of her skin lesions. She also is noted to be fussy and have a decreased appetite during her lesion outbreaks. There is no report of weight loss. She has a normal energy level. She has no other skin concerns. No cough, congestion, shortness of breath, nausea, vomiting, or diarrhea were reported. She has difficulty sitting down when she has a lesion on her buttock region, but otherwise, no reports of musculoskeletal difficulties. E.M. cries when her skin lesions erupt and whenever they are palpated, but otherwise, there is no sign of pain. The remainder of the review of systems is unremarkable.

Vital Signs

E.M.'s temperature is 100.1°F, her pulse is 111, her respirations are 26, and her blood pressure is 114/66 in the left leg. Her weight is 12.2 kg, which equates to the 50th percentile. Her height is 79 cm, which equates to the 10th percentile.

General

E.M. is a 2-year-old white girl who is well-developed, well nourished, and in no apparent distress. She cries during the examination but is consoled by her mother.

Skin: E.M. does not have a rash. She has 6 scars on the buttock and upper thigh regions measuring approximately 1 cm in diameter. There is an erythematous lesion on the right buttock measuring 4 cm. The lesion is firm, warm, and tender to palpation, and a pink-tinged border measuring 0.5 cm surrounds the lesion. There is no discharge from the lesion.

Head/Eyes/Ears/Nose/Throat: Results of an examination of the head, eyes, ears, nose, and throat are atraumatic and normocephalic. No thrush or oral lesions are noted. Conjunctiva are without injection bilaterally, and sclera are nonicteric bilaterally. Tympanic membranes are clear bilaterally. Moderate clear nasal mucus is present.

Lymphatics: A few shotty 0.5 cm inguinal lymph nodes are appreciated, but no abnormal lymphadenopathy is noted.

Cardiovascular: E.M. has a regular heart rate and rhythm without murmur; capillary refill is less than 3 seconds.

Respiratory: E.M.'s lungs are clear to auscultation bilaterally without wheezes.

Abdominal: No hepatosplenomegaly is noted; her abdomen is nontender and soft.

Musculoskeletal: E.M. is unable to sit on her buttocks because of lesion discomfort, but otherwise, she moves all extremities well and ambulates around the room.

Laboratory Tests: No laboratory tests have been conducted thus far.