A Rash in One Newborn Twin Sibling

The Case

A 38-week-gestation twin B boy with a known prenatal diagnosis of microcephaly was born via spontaneous vaginal delivery at a level 1 nursery. The infant was noted to have a generalized skin rash in various stages of healing at the time of delivery and was transferred to a level 3 NICU for further management.

The mother was a 26-year-old gravida 2, para 3 woman with a medical history of asthma and vitamin D deficiency. Routine prenatal laboratory findings were reassuring, except for group B Streptococcus positivity. The mother denied alcohol and illicit drug use or smoking during pregnancy. Medications during pregnancy were fluticasone, prenatal vitamins with additional supplemental vitamin D, and prescription oxycodone for pain issues. This was a spontaneously conceived dichorionic-diamniotic twin pregnancy. The pregnancy was uneventful, until routine level II prenatal ultrasonography noted twin B to have microcephaly, believed to be due to a stroke in the middle cerebral artery (MCA) distribution. Subsequent fetal magnetic resonance imaging (MRI) revealed the formation of a porencephalic cyst with associated gliosis and atrophy in the left frontoparietal region as well as some crossed cerebellar diaschisis and unilateral left ventriculomegaly. Due to the microcephaly, evaluation for maternal toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex (TORCH) syndrome was completed (Table 1). There was no history of maternal herpes lesions up until 2 weeks before delivery, when the mother was given oral valacyclovir. There was no maternal history of vulvovaginal candidiasis. She was regularly in the presence of her sister's cat, but never touched the cat or cleaned the litter box during the pregnancy. She had a prior history of chickenpox, but not during the pregnancy. There was no family history of hypercoagulable disorders, autoimmune conditions, or immunodeficiencies. Maternal thrombophilia evaluation was negative for antiplatelet antibodies, and results …