A 14-day-old female infant presented to the hospital with cough for 4 days, black discoloration of her lips and tongue, lethargy, decreased feeding for 1 day and 1 episode of blood-tinged emesis. She was born full term via normal vaginal delivery with a birth weight of 2.5 kg. Antenatal period was uneventful, and there was no maternal history of antibiotic use during pregnancy or of prolonged vaginal leakage.
She was exclusively breast-fed, and there was no history of local trauma. On examination, the baby was toxic appearing with a temperature of 38.9°C, heart rate of 180 beats/min, respiratory rate of 68 breaths/min, oxygen saturation of 94% in ambient air and capillary refill time of <3 seconds. The baby had respiratory distress with subcostal and intercostal retractions, and on chest auscultation, bilateral crackles were heard.
Examination of the oral cavity revealed black, gangrenous discoloration and induration of the lips, anterior part of the tongue and palate (Fig. 1). Laboratory investigations showed a white blood cell count of 20,200/mm3 with 70% neutrophils, 23% lymphocytes and 7% monocytes; hemoglobin of 14.7g/dL; platelet count of 340×109 /L and prothrombin time of 11 seconds with International normalized ratio of 1.07. Chest radiograph showed right upper lung consolidation.
A Doppler ultrasound of the bilateral carotid arteries was performed to rule out thrombosis of the major vessels supplying blood to head and neck and was normal. The clinical picture along with a culture result led to the diagnosis