Visual Diagnosis: Eosinophilia as a Clue to the Diagnosis of Infantile Bullous Pemphigoid.

1. Rachel McAndrew, MD* 2. Paul R. Massey, MD* 3. Lucia Z. Diaz, MD*,†,‡ 4. Moise L. Levy, MD*,†,‡ 1. *Department of Internal Medicine (Dermatology) and 2. †Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX 3. ‡Department of Pediatric/Adolescent Dermatology, Dell Children's Medical Center of Central Texas, Austin, TX A 3-month-old previously healthy boy presents to the emergency department with a 2-week history of a diffuse bullous eruption. The onset of eruption began with tense bullae on the hands and feet and spread proximally to involve the extremities, trunk, and face. He has no preceding illness. He has taken no medications, has no history of travel, and had no sick contacts before development of the rash. His most recent immunizations were 6 weeks before onset of the findings. The patient does not improve with use of amoxicillin and acetaminophen as prescribed by his primary care provider. The day before arrival the patient presented to a dermatologist who performed skin biopsies; results are pending. On initial examination, numerous urticarial pink plaques and papules admixed with tense bullae, some in a string-of-pearl configuration, are noted on the trunk and extremities (Fig 1A). The patient also has nearly confluent detachment of skin on the ankles and feet bilaterally (Fig 1B). The patient has tense bullae on the hands and genital region, and there are erosions on the palate. Figure 1. A. Urticarial pink papules and plaques with admixed tense bullae, some arranged in an annular string-of-pearls configuration, on the trunk and extremities. B. Predilection of involvement of the acral surfaces with tense bullae and nearly confluent epidermal detachment. Laboratory studies include a normal comprehensive metabolic panel and glucose-6-phosphate-dehydrogenase level, and a complete blood cell count reveals …