Denouement and Discussion

H istologicalexaminationshowedasubcornealpustulefilledwithneutrophilsandasuperficial inflammatory infiltrate in thedermis.Adirectpotassium hydroxide test, as well as a periodic acid–Schiff stain on the biopsyspecimen,showedsporesandpseudohyphae.Growth of Candida albicans was observed in a Sabouraud culture. Findings of the Gram stain and bacteria culture were negative.Treatmentwitha topical antifungal (nystatin)was initiated,whichcaused the skin lesions todisappear in7days. After 3 months of follow-up, the patient remained asymptomaticwithouttreatmentandtheungualdystrophyresolved. Mucocutaneous Candida infections are often observed in newborn infants because up to 20% to 25% of pregnant women have vulvovaginitis caused by this yeast. However, few published case reports can be found in the literature on congenital cutaneous candidiasis. It is not known whether such a scarcity of reports reflects underdiagnosis or underreporting of this condition. Congenital cutaneous candidiasis seems to result from chorioamnionitis acquired by an ascendant route through the intact fetalmembranefromthematernalvagina. Skin lesions are present from birth or appear during the first few hours of life; they consist of a maculopapular eruption that evolves to includevesiclesandpustules.Occurrenceofpalmoplantar vesicles and pustules, which evolve to desquamation, isoftendescribed.Occasionally,ungualdystrophy appearsasadelayedmanifestationof thedisease, as inour patient. Most of the patients show only cutaneous involvement; however, some patients may develop systemic disease with nonspecific signs of sepsis, hepatomegaly, sepsis, or death. If systemic involvement is suspected, thorax irradiation,ophthalmologicexamination,andblood,urine, and cerebral spinal fluid cultures are required. Blood culture results may be negative even when systemic involvement actually occurs. Hematogenous dissemination is not frequent but it can occur among premature neonates and infants with risk factors. Prematurity is generally accepted asa factorpredisposingtodisseminateddisease. Furthermore, someauthorshaveproposedthat in infantswithcongenital candidiasis,disseminated infectionor increasedrisk of disseminated infection should be suspected in the setting of respiratory distress or other laboratory or clinical signs of sepsis; birth weight lower than 1500 g; treatment withbroad-spectrumantibiotics;extensiveinstrumentationinvasive procedures; positive systemic culture results; and evidence of an altered immune response. Differential diagnosis must be done as with other neonatalpustulovesicularconditions. Thediagnosisisconfirmed byidentificationofCalbicansonadirectpotassiumhydroxide test or positive findings of a culture in Sabouraud mediumfromacutaneouspustule. Ifadiagnosis is stillunclear, abiopsywithaperiodicacid–Schiffstaincouldbeperformed. Treatment of candidiasis in the neonate requires an effective antifungal agent and, if possible, elimination of all risk factors for ongoing candidemia. In most term infants with congenital cutaneous candidiasis, the disease is limited to the skin, umbilical cord, and placenta. In these patients, topical antifungal agents are indicated (nystatin or azole formulations), although spontaneous resolution has also been described. Amphotericin B (0.5-1 mg/kg/d) is the recommendedantifungal agent for the treatmentof candidemia and any form of invasive candidiasis in the neonate, although lipid-associatedamphotericinBpreparations (3-5 mg/kg/d) are preferred in those cases with invasive candidiasis and severe preexisting renal insufficiency. Fluconazole (6-12 mg/kg/d) can be used as alternative therapy to amphotericin B, if the Candida species is identified and the susceptibility is shown. Flucytosine (50-100 mg/kg/d) is used in combination with amphotericinB for centralnervous systeminfection. There arenocontrolledclinical trials toprovide theoptimal length of therapy. The topical antifungal agent must be used until the lesions resolve, and the systemic therapy must be used a minimum of 21 to 28 days.