A 7-month-old female infant presented with failure to thrive. She was breastfed till 3 months of age, thereafter switched to soy-based milk formula. There was no history to suggest excess energy losses, recurrent infections or chronic diarrhoea. Three months after switching to exclusive soy-based milk formula, parents noticed significant enlargement of both breasts. Clinical examination was unremarkable except for enlargement of both breasts. None of the other secondary sexual characteristics were present. Initial blood investigations showed hyponatraemic hypokalaemic hypochloraemic metabolic alkalosis, which corrected after 2 days with intravenous hydration. The patient subsequently maintained normal electrolyte balance with recommended intake of cow’s milk-based standard formula milk.Further exploration of her soy-based milk revealed that it was low in sodium and calories, unsuitable for children. This was not a standard and approved infant soy-based formula milk. She achieved excellent weight gain and reduction of breast size on cessation of soy-based milk formula.

Varicella zoster virus (VZV) infections are known to be atypical and severe in immunocompromised patients. An eight-year-old girl presented with extremely painful, atypical skin lesions and features of meningitis and pneumonitis. On investigation, she was found to be human immunodeficiency virus (HIV) infected, with very low CD4 count. A diagnosis of ‘progressive varicella syndrome’ was made, and the child was started on antiretroviral therapy and IV acyclovir. This resulted in a complete resolution of all the clinical features. However, the skin lesions promptly relapsed when acyclovir was withdrawn. Oral Acyclovir was started, and had to be continued to keep the disease under control.

We report a case of scrub typhus with coexistent Pseudomonas aeruginosa skin infection in the same patient. A 6-year-old Chinese boy presented with 5 days of fever, 2 days of right thigh swelling, and an insect bite mark over the swelling. A full blood count had been performed prior to hospital consultation, and showed neutropenia and thrombocytopenia. Initial clinical examination revealed a tender erythematous induration with a central punctum on his right thigh, which progressed to form a rolled-up papule with black central necrosis. The clinical suspicion was of an eschar, although ecthyma gangrenosum could not be ruled out. He had recently returned from a recreational trip in the United States 3 weeks earlier, and had travelled to Wisconsin and Las Vegas. He was treated initially for right thigh cellulitis with parenteral ampicillin and cloxacillin, but after infectious disease consultation, he was commenced on intravenous ciprofloxacin. A wound culture grew P. aeruginosa, while rickettsial serology was positive for Orientia tsutsugamushi. He responded clinically to ciprofloxacin and was discharged well, and an outpatient review showed significant improvement of his cutaneous lesion.

This case describes an uncommon presentation of herpes zoster in an adolescent with viral meningitis and concomitant genital shingles. A 15-year-old immunocompetent girl with background of well-controlled Graves’ disease presented with 3 days of fever, frontal headache, terminal neck stiffness and photophobia. This was preceded by 4 days of pain and itch over vaginal and anal region. She had one dose of varicella vaccination at 18 months old and developed mild primary varicella infection around 5 years of age. Varicella zoster virus DNA was detected both in cerebrospinal fluid and in vesicles over her right labial majora. While there is no international consensus on the recommended duration of treatment for zoster with neurological complications, she was treated with intravenous acyclovir for 10 days with good clinical response. Her fever, headache and neck stiffness resolved after 2 days and genital lesions resolved after 9 days of antiviral therapy.