gianotti - crosti syndrome was described in 1955 by gianotti who later coined a more descriptive term  papular acrodermatitis of childhood ( pac ) for this disease . some subsequent publications by the same author along with crosti illustrated the complete clinical presentation of the disease . gianotti - crosti syndrome presents with small papulovesicular eruptions distributed symmetrically over extensor surface of bilateral lower and upper limbs and face in children . lesions are tiny , lentil - shaped or hemispherical , erythematous , edematous , commonly monomorphic papular , and sometimes papulovesicular . individual lesion can coalesce to form larger patches and plaques , but a size more than 8 - 10 mm is generally rare . skin manifestation is usually preceded or accompanied by mild constitutional prodrome of slight rise of temperature , lassitude , and signs like lymphadenopathy , most commonly involving axillary and inguinal area . here , we report an unusual case of gianotti - crosti syndrome in a very young infant aged one and half months . a male infant , aged one and half month born vaginally at term following uneventful pregnancy , weighing 2.9 kg at birth and 4.5 kg at presentation , on exclusive breast - feeding , was hospitalized with remittent , moderate fever of 7 days duration and hemorrhagic papulovesicular eruptions for 5 days duration . there were extensive hemorrhagic vesicles along with papules over hands , feet , lower and upper limbs ( mostly on extensor surfaces ) , face , and lips but sparing other parts of the oral mucosa [ figures 1 and 2 ] . hemorrhagic vesicles on hands and upper limbs of the infant with papular acrodermatitis of childhood extensive hemorrhagic vesicles on lower limbs in the same patient there was no icterus or significant lymphadenopathy , but moderate pallor was present . there was mildly enlarged soft spleen ( 2 cm ) and liver ( 2.5 cm ) as found on palpation of abdomen . peripheral blood examination showed low hemoglobin concentration ( hb-8.8% ) , leukocytosis ( 20800/cmm ) with lymphocytosis ( neutophil-30 , lymphocyte-64 ) . characteristically , 26% of the total lymphocytic population showed atypicality ( mostly plasmacytoid form , a few were monocytoid form ) and normal platelet count ( 2.4 lacs / cmm ) . igm antibody against epstein bar viral capsid antigen ( vca ) was significantly elevated ( igm-31.51 u / ml , reference range : 0 - 8 u negative , 8 - 12 borderline ) . a diagnosis of gianotti - crosti syndrome was made , and causative role of ebv was suggested . rash started improving from 6 day of admission and resolved completely with mild hypopigmentation and scaling by 11 day . [ figure 3 ] . hemorrhagic crust persisting on lips while cheeks showing healed lesions with slight erythema and hypopigmentation most of the initial work suggested hepatitis b virus ( hbv ) as the etiological agent . anicteric hepatitis and significantly raised hepatic transaminases ( 1000 - 2000 iu / ml ) , a feature that is rare with other etiologies , are evidences in favor of hbv - induced pac . however , this initial suspicion was not sustained in more recent observations from united states , italy , and japan . coxsackie virus , cytomegalo vurus , respiratory syncytial virus , hhv-6 , parainfluenza virus , parvovirus b-19 , polio virus and vaccines for mmr , dpt , japanese b encephalitis , oral polio vaccine and even hiv infection were also implicated as causes of pac . papular urticaria , henoch - schnlein purpura ( hsp ) , immunobullous diseases , erythema multiforme , acrolocated pityriasis lichenoides , and hand - foot and mouth disease ( hfmd ) may clinically mimic pac , but clinical distinction may not be difficult . hsp is characterized by successive crops of larger lesions , which are found over lower limbs and buttocks in older children with prominent systemic symptoms like abdominal pain and joint pain . distribution , characters of individual lesions , clinical course , and examination finding were not suggestive of any of the bullous diseases seen at very early ages like chronic bullous diseases of childhood , childhood bullous pemphigoid , herpes gestationis and hfmd . histological findings in pac include moderately dense lymphocytic infiltrate along with histiocytes in the perivascular area and endothelial swelling . although histology and more sophisticated tests like immunofluorescence ( if ) and lesional fluid culture for bacteria or virus may have some role in differentiating pac from other mimicking disorders , it is known that histological findings may not have any definitive role in confirmation of diagnosis in pac . in a study done on more than 300 patients of pac , the most commonly affected age group was 6 months to 14 years with a mean of 2 years . occasionally purpura had been reported to be induced following application of tourniquet . till reporting this case , however , rapid recovery without any complication indicated that widespread hemorrhage might not be a poor prognostic marker . gianotti - crosti syndrome may present with extensive hemorrhagic lesion and may involve infant of less than 2 months age .
gianotti - crosti syndrome is parainfectious exanthematous disease having unique presentation of small papulovesicular eruptions symmetrically over extensor surface of limbs and face in children . 
 hemorrhagic lesions are very rare and are always localized . here , a case of ebv - induced gianotti - crosti syndrome with extensive hemorrhagic vesicles in a one and half month old infant , possibly induced by epstein barr virus , is reported . 
 neither the involvement of the disease at this early age nor the extensive hemorrhagic vesicles as the predominant presentation is reported before .