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Multifocal ulcerations in extreme prematurity

A male neonate, born at corrected gestational age of 25 weeks and 4 days by spontaneous vaginal delivery to a 25yearold gravida 2 para 1 woman with preterm labor, was admitted to the neonatal intensive care unit with respiratory distress syndrome requiring mechanical ventilation. His course was complicated by hyperglycemia, hypernatremia, spontaneous bowel perforation requiring Penrose drain placement, and hemodynamic instability requiring dopamine inotropic support. The pediatric dermatology service was consulted 7 days after birth for necrotic yellow to brown eschars which had developed over the course of 2 days on the left thigh and subsequently on the buttocks and back (Figures 1 and 2), from which initial superficial swabs had not yielded growth of any organism. Punch biopsies were performed for histology (Figure 3), including staining with periodic acid Schiff with diastase (PASD, Figure 4), and culture.