Neonatal Violaceous Skin Lesions: Expanding the Differential of the “Blueberry Muffin Baby”

Disseminated Juvenile Xanthogranuloma with a Novel MYH9-FLT3 Fusion Presenting as a Blueberry Muffin Rash in a Neonate

Juvenile xanthogranuloma (JXG) is a benign proliferative histiocytic disorder of the dendritic cell phenotype. It mostly presents in the pediatric age group as a solitary skin lesion. We describe a rare case of an infant born with disseminated JXG who presented with a blueberry muffin rash at birth. A term infant was noted to have multiple petechiae, purple nodules, and macules (1 mm-2 cm in diameter) and hepatosplenomegaly, at the time of birth. Further investigations revealed thrombocytopenia and direct hyperbilirubinemia and a magnetic resonance imaging showed scattered tiny foci of restricted diffusion in multiple areas of the brain. Patient received multiple platelet transfusions in the first few weeks with gradual improvement in thrombocytopenia. Ultimately, a biopsy of one of the lesions revealed the diagnosis of disseminated JXG with notable atypical features. Somatic mutation analysis showed a novel MYH9-FLT3 fusion, but a bone marrow biopsy was negative. The lesions faded over time, relative to patient's growth and normal neurodevelopment was noted at 18 months of age. JXG should be considered in the differentials of blueberry muffin rash in an infant. Although, JXG is mostly a self-limited condition, congenital disseminated JXG may be associated with significant morbidity and mortality.

Extramedullary hematopoiesis secondary to COVID-19: A first case report in a newborn

A 39 weeks newborn baby was born with blueberry muffin macules and papules on her back. Skin biopsy was performed and showed extramedullary hematopoiesis. The mother who was infected by COVID-19 infection at 35 weeks of pregnancy did not have any other risk factor for extramedullary hematopoiesis, thus making this viral infection the most likely cause of blueberry muffin rash.

Perinatal-lethal Gaucher disease presenting with blueberry muffin lesions

"Blueberry muffin baby" is an expression applied to newborns displaying a generalized purpuric rash caused by dermal erythropoiesis. This presentation is typically associated with TORCH (toxoplasmosis, other, rubella, cytomegalovirus, and herpesvirus) complex infections. However, alternative diagnoses should be considered, including other infections, neoplastic diseases, congenital vascular lesions, and metabolic diseases. We report a case of perinatal-lethal-type Gaucher disease presenting with cholestasis, hepatosplenomegaly, persistent thrombocytopenia, and blueberry muffin-like skin lesions.

Clinical and molecular characterization of novel deletions causing epsilon gamma delta beta thalassemia: Report of two cases

Epsilon gamma delta beta (εγδβ)⁰ - thalassemia is a very rare disorder that results from large deletions in the β-globin gene cluster which abolish all regional globin chain gene expression from that allele. Since it is an exceedingly rare cause of neonatal anemia and is not detected by routine newborn screening, it is usually not suspected clinically and commonly undiagnosed or misdiagnosed. In this study, we describe two patients diagnosed in our hospital with (εγδβ)⁰-thalassemia based on the results obtained from DNA microarray analysis of their peripheral blood. The first patient of mixed European descent presented as a neonate with microcytic hemolytic anemia, hyperbilirubinemia, hypoglycemia and hypothermia, and was found to have a 2.2 Mb loss that included the entire β-globin gene cluster and the locus control region (LCR). The second patient, also of mixed European descent, presented in the neonatal period with anemia, thrombocytopenia and cutaneous extramedullary hematopoiesis, and was found to have a 59 kb loss that included the β-globin LCR, HBE1, HBG1, and HBG2 genes. Both cases highlight the importance of recognizing the clinical features of (εγδβ)⁰-thalassemia and implementing appropriate testing to clarify the diagnosis and manage the condition.

Fetal hypoxia secondary to severe maternal anemia as a causative link between blueberry muffin baby and erythroblastosis: a case report

Background

Neonatal blueberry muffin lesions are rare cutaneous eruptions, presenting as transient, non-blanching, red-violaceous papules, mostly localized in the trunk, head and neck, attributable to a marked dermal hematopoietic activity. Congenital infections of the TORCH complex (toxoplasmosis, other, rubella, cytomegalovirus and herpes) and hematological disorders have been classically associated with this neonatal dermatological manifestation. We report for the first time an unusual presentation of blueberry muffin lesions in a neonate born from a mother affected by severe anemia during pregnancy.

Case presentation

A male, white Caucasian, neonate showed a cutaneous rash at birth, suggestive of “blueberry muffin”-like lesions. These cutaneous lesions were associated with marked elevation of the circulating nucleated red blood cells, and with ultrasound findings of peculiar brain ischemic porencephalic lesions. The clinical features of spontaneous disappearance and the association with marked erythroblastosis strongly suggest that these dermatological findings may be the consequence of an extramedullary hematopoiesis unexpectedly evoked by the intrauterine chronic exposure to hypoxia caused by severe maternal anemia.

Conclusions

In conclusion, fetal hypoxia secondary to severe maternal anemia may play a causative and unreported role in the development of neonatal blueberry muffin lesions.

Cutaneous metastases in neonates: a review

Two hundred eight neonates with malignant tumors and cutaneous metastases were reviewed. Malignancies most often associated with cutaneous metastases, in order of rank, were leukemia, multisystem Langerhans cell histiocytosis, neuroblastoma, rhabdoid tumor, rhabdomyosarcoma, primitive neuroectodermal tumor, choriocarcinoma, and adrenocortical carcinoma. Bluish skin nodules producing the "blueberry muffin baby"-like appearance were the most common dermatologic finding in 171, or 82% of 208 neonates. The tendency of newborns to present with skin nodules is one of the significant differences between malignancies in younger and older children. Patients with rhabdoid tumor and rhabdomyosarcoma had the lowest survival rates, 4% and 15%, respectively, compared with leukemia, 37.5%, and neuroblastoma, 58%. Overall survival was 39%.

Blueberry muffin rash as the presenting sign of Aicardi-Goutières syndrome

A 36-week gestation singleton male infant was born with hypoglycemia, thrombocytopenia, transaminitis, microcephaly, and a generalized eruption of bluish-red nonblanching macules and papules. Head computed tomography showed intracranial calcifications and enlarged ventricles. Skin biopsy was consistent with extramedullary hematopoiesis, with no evidence of neoplastic infiltrate. Family history was notable for parental consanguinity and twin sisters with the diagnosis of Aicardi-Goutières syndrome, a rare autosomal recessive progressive encephalopathy. Although the infant's clinical presentation at birth suggested an infectious etiology, extensive testing for infection, including TORCH titers, was negative. Cerebrospinal fluid analysis revealed persistent lymphocytosis and an elevated interferon alpha level, consistent with the diagnosis of Aicardi-Goutières syndrome. Although there have been no reported cases of a blueberry muffin rash in Aicardi-Goutières syndrome, it is biologically plausible for this cutaneous manifestation to occur in the setting of a genetic condition that mimics the clinical phenotype of a congenital viral infection. As the capacity to test for different infectious etiologies and genetic syndromes increases, so must the differential diagnosis of a neonatal blueberry muffin rash. It is important to identify these rare syndromes because of their prognostic implications, risk of recurrence with future pregnancies and need for prompt genetic counseling.