Edwin F. de Zoeten, MD, PhD; Jonathan Markowitz, MD, MSCE; Kathleen M. Loomes, MD; Petar Mamula, MD Series Editors: Petar Mamula, MD; Kathleen M. Loomes, MD; David A. Piccoli, MD


August 19, 2008

Case Presentation

A previously healthy, 9-month-old girl presented with a skin rash to her pediatrician and was treated with a 10-day course of cefdinir for presumed impetigo. She developed diarrhea after 1 day of therapy and had up to 20 loose stools per day. The patient was solely on a cow's milk-based formula at the time of presentation, which was then changed to a soy formula. After antibiotics were discontinued the diarrhea persisted, prompting a change to a protein hydrolysate formula. However, the diarrhea continued and the skin rash worsened, resulting in hospitalization a few weeks later. She had no history of fever, vomiting, or hematochezia. No other symptoms were present.

The patient's past medical history was unremarkable. She was born at full term with a birth weight of 3.8 kg. She was conceived by in vitro fertilization. Her growth was normal. There were no significant medical issues, and other than cefdinir she was on no medications. She had no sick contacts or history of travel. The family history revealed that her mother had hypothyroidism, but there was no history of any gastrointestinal illnesses. The social history was noncontributory.

Upon examination at the time of hospitalization, the patient's vital signs were normal. Her weight and height were at the 50th percentile. She was alert, awake, well-developed, mildly dehydrated, and in no acute distress. Skin exam revealed a generalized erythematous rash consistent with staphylococcal scalded skin syndrome. Lung and heart examinations were normal. The abdomen was soft, nontender, nondistended, without hepatosplenomegaly, and with normoactive bowel sounds. Rectal exam was normal and negative for occult blood. Musculoskeletal and neurologic exams were unremarkable.

Laboratory evaluation was obtained, including complete blood count with differential and electrolytes, which were normal. Stool testing for ova and parasites, bacterial culture, and Clostridium difficile toxins A and B was negative. No white blood cells or eosinophils were noted in stool. Reducing substances were measured at 0.75% to 2% with a stool pH of 5. Results of the glucose breath test were normal. Oral feedings were initially held and diarrhea ceased. However, upon reintroduction of enteral feeding with an elemental amino acid-based formula, the diarrhea resumed.

How would you interpret the results of the investigations at this point in work-up?

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