Scabies outbreak in NICU reveals challenges with diagnosis

Photo of Vini Vijayan
Vini Vijayan

The rare occurrence of a scabies outbreak in the NICU of a children’s hospital underscored just how difficult the disease is to diagnose and treat in that setting, according to researchers.

Vini Vijayan, MD, assistant professor of pediatrics at the University of Arkansas for Medical Sciences and a faculty member in the pediatric infectious diseases section at Children’s Arkansas, told Infectious Diseases in Children that when scabies outbreaks do occur in health care settings, they are more likely to be encountered in long-term care facilities and nursing homes.

“This was a unique situation because scabies typically occurs in young children and spreads by close physical contact,” she explained. “Infants in the NICU have been hospitalized since birth and have multiple comorbidities, and hence prolonged, direct contact with children and family members is limited. Health care providers may not even consider diagnosing scabies for these babies.”

According to Vijayan and colleagues, the outbreak occurred between April and July 2016 at a 104-bed, level 4 NICU in an academic children’s hospital. It was traced to the parents of a 35-week-old infant, who was identified as the index patient.

Health care personnel originally considered a diagnosis of contact dermatitis when papules and pustules developed on the child’s right arm. However, the rash spread to the child’s abdomen, legs and back. A scraping collected 7 days after symptom presentation revealed the presence of mites.

“In this outbreak, lack of familiarity with the clinical presentation of neonatal scabies led to a 7-day delay in diagnosis,” the researchers admitted.

Photo of scabies mite 
Scabies outbreaks, caused by mites, rarely occur in the NICU setting. This outbreak in a unit located in an academic children's hospital demonstrates some of the diagnostic challenges associated with scabies in neonates.
Source: Adobe

The researchers noted that neonatal scabies typically presents with pustules, vesicles or papules involving the face, scalp, palms and soles. These symptoms differ from those in adults, who usually present with intertriginous papules and burrows.

“A provider encountering a critically ill neonate with a vesicular or pustular rash may be more likely to consider other diagnoses such as neonatal herpes, neonatal pustulosis or contact dermatitis due to adhesives,” Vijayan said.

In the NICU, 139 neonates were exposed to scabies, with 39 aged 2 months or older and 100 aged younger than 2 months. Every child aged 2 months and older were treated with 5% permethrin. Children aged younger than 2 months were left untreated because of limited safety data in their age group. Instead, these children were placed on contact precautions for the remainder of their incubation period.

After the outbreak was contained, three secondary cases of scabies occurred, with two cases identified in nurses and one in an occupational therapist who developed symptoms 6 weeks after contact with the index case.

“Scabies is a relatively common infestation,” Vijayan said. “A family member or health care provider in the NICU can easily transmit [them] through direct and prolonged skin-to-skin contact. To prevent scabies outbreaks, providers should consider scabies when evaluating an infant or visitors with an unexplained rash. Prompt diagnosis, treatment and implementation of appropriate isolation and infection control practices are essential.” – by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.

Photo of Vini Vijayan
Vini Vijayan

The rare occurrence of a scabies outbreak in the NICU of a children’s hospital underscored just how difficult the disease is to diagnose and treat in that setting, according to researchers.

Vini Vijayan, MD, assistant professor of pediatrics at the University of Arkansas for Medical Sciences and a faculty member in the pediatric infectious diseases section at Children’s Arkansas, told Infectious Diseases in Children that when scabies outbreaks do occur in health care settings, they are more likely to be encountered in long-term care facilities and nursing homes.

“This was a unique situation because scabies typically occurs in young children and spreads by close physical contact,” she explained. “Infants in the NICU have been hospitalized since birth and have multiple comorbidities, and hence prolonged, direct contact with children and family members is limited. Health care providers may not even consider diagnosing scabies for these babies.”

According to Vijayan and colleagues, the outbreak occurred between April and July 2016 at a 104-bed, level 4 NICU in an academic children’s hospital. It was traced to the parents of a 35-week-old infant, who was identified as the index patient.

Health care personnel originally considered a diagnosis of contact dermatitis when papules and pustules developed on the child’s right arm. However, the rash spread to the child’s abdomen, legs and back. A scraping collected 7 days after symptom presentation revealed the presence of mites.

“In this outbreak, lack of familiarity with the clinical presentation of neonatal scabies led to a 7-day delay in diagnosis,” the researchers admitted.

Photo of scabies mite 
Scabies outbreaks, caused by mites, rarely occur in the NICU setting. This outbreak in a unit located in an academic children's hospital demonstrates some of the diagnostic challenges associated with scabies in neonates.
Source: Adobe

The researchers noted that neonatal scabies typically presents with pustules, vesicles or papules involving the face, scalp, palms and soles. These symptoms differ from those in adults, who usually present with intertriginous papules and burrows.

“A provider encountering a critically ill neonate with a vesicular or pustular rash may be more likely to consider other diagnoses such as neonatal herpes, neonatal pustulosis or contact dermatitis due to adhesives,” Vijayan said.

In the NICU, 139 neonates were exposed to scabies, with 39 aged 2 months or older and 100 aged younger than 2 months. Every child aged 2 months and older were treated with 5% permethrin. Children aged younger than 2 months were left untreated because of limited safety data in their age group. Instead, these children were placed on contact precautions for the remainder of their incubation period.

After the outbreak was contained, three secondary cases of scabies occurred, with two cases identified in nurses and one in an occupational therapist who developed symptoms 6 weeks after contact with the index case.

“Scabies is a relatively common infestation,” Vijayan said. “A family member or health care provider in the NICU can easily transmit [them] through direct and prolonged skin-to-skin contact. To prevent scabies outbreaks, providers should consider scabies when evaluating an infant or visitors with an unexplained rash. Prompt diagnosis, treatment and implementation of appropriate isolation and infection control practices are essential.” – by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.