A 28-year-old woman with polyhydramnios who was previously treated for syphilis was admitted to the hospital in labor at 29 weeks' twin gestation.
Both infants developed respiratory distress and were treated accordingly. Results of physical examination and imaging studies showed a left-upper-quadrant radiolucent mass in both twins, considered typical of pyloric atresia (Fig 1). In the first hours it was also noted that on slight pressure their skin sloughed off, revealing bullous formation (Fig 2).
Skin biopsy and microbiologic diagnostic studies were performed, and antibiotics were administered. In the next few days, the skin lesions continued to develop and were associated with bloody oronasal secretions. Results of all microbiologic studies, including virology and syphilis serology, were negative. After 1 week, the infants became thrombocytopenic and developed upper gastrointestinal tract bleeding. Both continued to have respiratory infiltrates, unstable circulatory volumes, and abnormal blood chemistries. Despite some improvement with therapy, the infants