Answers to the Clinical Quiz in SSMJ Vol 3, issue 1. February 2010
Case history: This picture shows a twelve-day old girl who was born by Caesarean section to a healthy mother at Kajo Keji Hospital. The mother was primagravida. She had no history of recreational drug use and was not on any regular prescription drugs including corticosteroids. The indication for her delivery by emergency caesarean section was failure of progress and foetal distress. The baby was delivered in healthy condition, but on the following day she had developed what appeared to be 'itching' as noted from her moving her arms over her breasts frequently. Mother was normotensive, had no vaginal discharge and her HIV status was negative.
Question 1. How many abnormalities can you identify in the above picture?
Answer. Three abnormalities:
- Bilateral gynaecomatsia
- Left breast mastitis
- Pustular skin lesions anterior left shoulder, anterior right upper arm and left side of face.
Question 2. What investigations would you carry out?
Answer. Full blood count, C-reactive protein, syphilis serology, HIV test even if her mother’s test was negative, pus swab from pustular lesions for gram staining, culture and sensitivities to isolate the offending organism and guide choice of appropriate antibiotics.
Question 3. What treatment would you start whilst waiting for results of tests?
Answer. A broad-spectrum antibiotic such as Ampicillin.
The bilateral breast enlargement is most likely due to maternal oestrogenic stimulation of the infant’s mammary glands. It is likely to resolve over the next three to six months without intervention. Some of the tests listed above may not be available in Kajo Keji Hospital. The listed tests are the minimum the clinician should carry out if there was a well-equipped laboratory.
Quiz contributed by Dr Kandyang Modi Dumo Jansuk, Medical Officer in Obstetrics and Gynaecology, Juba Teaching Hospital. Answers from Dr Eluzai Hakim, Editor.