An evaluation is requested for a 28-day-old male infant who presents to the outpatient cli… — USMLE Step 2 CK

An evaluation is requested for a $28$ -day-old male infant who presents to the outpatient clinic in late January with worsening nasal congestion, poor sleep, and a mild cough over the past $3$ days. The parents also inquire about a facial rash that erupted two days ago. The infant's $5$ -year-old sister has severe asthma and recently missed school due to an upper respiratory infection. The infant was born at $39$ weeks gestation with no perinatal complications. He is breastfeeding slightly less than usual but has adequate urine output. Vital signs include a temperature of $37.3$ °C ( $99.1$ °F), pulse of $152$ /min, and respirations of $54$ /min. Oxygen saturation is $95$ % on room air. Physical examination reveals a well-hydrated, non-toxic appearing infant with copious clear rhinorrhea. Lung auscultation demonstrates prolonged expiration, diffuse high-pitched wheezes, and mild subcostal retractions. Skin examination of the forehead and cheeks shows scattered $1$ - to $2$ -mm erythematous papules and pustules without comedones. Which of the following is the most appropriate next step in management?

Reassurance and supportive care with saline nasal dropsAnswer
B
Trial of nebulized albuterol therapy
C
Application of topical mupirocin to the facial lesions
D
Admission for intravenous ampicillin and gentamicin
E
Administration of the oral live-attenuated rotavirus vaccine

Answer

Reassurance and supportive care with saline nasal drops

The infant is presenting with two concurrent, self-limiting conditions: viral bronchiolitis and neonatal cephalic pustulosis. The respiratory symptoms, including copious rhinorrhea, diffuse wheezing, and mild retractions, occurring during winter in a young infant with a sick contact, are classic for bronchiolitis. This condition is most commonly caused by Respiratory Syncytial Virus (RSV). The management for mild-to-moderate bronchiolitis in an infant without hypoxia (oxygen saturation

\geq 90

%) or severe respiratory distress is entirely supportive. The focus is on maintaining hydration and clearing the airway with saline nasal drops and gentle suctioning. Additionally, the facial rash consisting of erythematous papules and pustules without comedones, appearing at approximately

3

4

weeks of age, is characteristic of neonatal cephalic pustulosis (formerly known as neonatal acne). This is a benign inflammatory reaction to Malassezia species and requires only routine gentle washing with water; it does not require topical antibiotics. Therefore, reassurance and supportive care constitute the single best next step in management.

Step-by-Step Solution

Analyze the respiratory presentation (rhinorrhea, wheezing, mild retractions, sick contact, winter season).

Diagnosis of mild-to-moderate viral bronchiolitis.

Classic symptoms and epidemiology point to a viral etiology, likely Respiratory Syncytial Virus (RSV), rather than asthma or bacterial pneumonia.

Evaluate the dermatologic presentation (papules and pustules on cheeks/forehead at 4 weeks of age, no comedones).

Diagnosis of neonatal cephalic pustulosis.

The age of onset and lesion morphology without systemic infectious signs confirm a benign neonatal rash rather than a primary bacterial infection.

Determine the appropriate interventions for both diagnoses.

Supportive care with saline nasal drops and reassurance.

Both viral bronchiolitis and neonatal cephalic pustulosis are self-limiting. Evidence-based guidelines recommend against bronchodilators, systemic antibiotics, or topical antibiotics for these respective conditions.

Key Concept

Management of viral bronchiolitis and recognition of benign neonatal cephalic pustulosis.

Estimated Time:1m 30s

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