2. Jackson H, Vion B, Levy PM. Generalized eruptive pustular drug rash due to cephelexin. Dermatologica (Basel) 1988;177:292–294. 3. Sidoroff A, Halevy S et al. Acute generalized exanthema- tous pustulosis – a clinical reaction pattern. J Cutan Pathol 2003;28:113–119. 4. Haro GV, Sanchez VJ, Ruiz AP et al. Acute generalized exanthematous pustulosis with CMV infection. Int J Derm 1996;35:735–737. 5. Belda J, Walter F, Ana C. Acute generalized exanthematous pustulosis (AGEP). Case report. Rev Inst Med Trop Sao Paulo 2005;47:171–176. 6. Beylot C, Doutre MS, Beylot BM. Acute generalized exanthematous pustulosis. Semin Cutan Med Surg 1996;15:244–249. 7. Baker H, Ryan TJ. Methotrexate in psoriasis. Lancet 1968;2:1395. 8. Markus B, Urs CS, Simone S et al. T-cell involvement in drug-induced acute generalized exanthematous pustulosis. J Clin Invest 2001;107:1433–1441. KUMAR RITEN, M.D.* QURESHI SHAHINA, M.D.* JAKUS JEANNETTE, M.D.à PALMA-DIAZ F. MIGUEL, M.D.  *Department of Pediatrics and  Department of Pathology, Downstate Medical Center, State University of New York, Brooklyn, New York, and àDepartment of Pediatrics, Mount Sinai Medical Center, New York, New York NEONATAL FROSTBITE WITH GANGRENE OF TOES Abstract: Gangrene of the extremities in the neo- natal period is rare. Etiology is not identified in most cases and management is usually conservative. We describe an unusual case of an abandoned neonate with marked hypothermia, who was brought to us with gangrene of toes, during a severe winter. The toes auto- amputated after 2 weeks. A negative sepsis screen, normal Doppler study, and absence of evidence of hypercoagulable state prompted us to incriminate localized cold injury (frostbite) as the probable cause of gangrene in this newborn infant. Newborn infants are at increased risk for cold injury, because of a relatively larger body surface area in relation to weight, little subcutaneous fat, and absence of shiv- ering thermogenesis. In severe hypothermia, the periph- eral circulation may be compromised, leading to gangrene and potential loss of the affected area. We describe gangrene of toes in a neonate as a consequence of localized cold injury and severe hypothermia. CASE REPORT An abandoned female neonate, weighing 2.9 kg, was found along the roadside by a police constable and brought to our hospital during a winter night in January 2008. The child was wrapped in a cotton cloth; however, both feet were uncovered. The umbilical cord had not yet fallen off. No antenatal or perinatal history was available as the parents could not be traced. Axillary temperature was 31.8°C. Toes of both the lower limbs showed pur- plish discoloration with edema and blister formation (Fig. 1). There were no other foci of infection. Investi- gations showed a negative sepsis screen (TLC 8 · 10 9 ⁄ L, I: T ratio 0.11, CRP <6 mg ⁄ dL, micro-ESR 3 mm in the 1st hour, absolute neutrophil count 2.5 · 10 9 ⁄ L); blood glucose 86 mg ⁄ dL; hematocrit 50%; and VDRL and HIV serology were negative. Blood culture and blister fluid culture were sterile. Doppler studies showed normal flow beyond the popliteal artery. Protein C and S levels were normal. The infant was negative for anticardiolipin IgM and homocysteine was <2.5 lmol ⁄ L. The baby was re-warmed within 1 hour using a servo-controlled radiant warmer in skin mode. Soon after re-warming, she became active and started accepting oral feedings. Dressing of the involved areas with soframycin ointment was carried out twice daily. The toes developed gangrene and auto-amputated after 2 weeks. After 3 weeks of stay in the hospital, the baby was discharged and sent to an orphanage. The baby is under regular follow-up. Figure 1. Toes of the baby showing purplish to blackish discoloration with edema and blister formation. Address correspondence to Kumar Riten, M.D., Department of Pediatrics, Downstate Medical Center, State University of New York, Brooklyn, NY, or e-mail: ritenkumar@yahoo.com. Brief Reports 625