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An Unusual Cause of Sepsis and Meningitis in a Neonate
CASE STUDY
An Unusual Cause of Sepsis and Meningitis in a Neonate Veronica K. Goytia, MD,* Gail J. Demmler, MD,* Pia S. Pannaraj, MD,* Ruth Ann Luna, MS, C.L. Sp. (M.B.),†,‡ and James Versalovic, MD, PhD†,‡
A
26-day-old male infant presented to an Emergency Department (ED) in September, 2005, with a 1-day history of irritability, labored breathing, and decreased activity. He was a former 2547-g, 34 weeks of gestation premature infant born by spontaneous vaginal delivery to a 27-year-old rubellanonimmune woman whose pregnancy was complicated by prolonged rupture of membranes, treated with intrapartum intravenous ampicillin. Apgar scores were 8 at 1 minute and 9 at 5 minutes. A sepsis evaluation was performed because the infant had respiratory distress during the first day of life. Ampicillin and gentamicin were administered until bacterial culture results were sterile after 48 hours of incubation; phototherapy also was administered for physiologic jaundice. He was discharged home on day of life 7 and did well until his presenting illness. Physical examination was notable for fever (39°C) and periodic breathing accompanied by cyanosis. Supplemental oxygen was administered, and bacterial cultures of blood and urine were obtained. Doses of ampicillin, cefotaxime, and vancomycin were administered intravenously, and the infant was transferred to Texas Children’s Hospital (TCH) for further management. On arrival at TCH, the infant was alert but irritable and sucked his pacifier vigorously. His temperature was 39°C, heart rate was 170/min, respiratory rate was 60/min, blood pressure was 90/60 mm Hg, and oxygen saturations were 98 to 100 percent on room air. The physical examination was otherwise normal for his age. Social and exposure history
*Section of Infectious Diseases, Departments of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX. †Section of Infectious Diseases, Departments of Pediatrics Pathology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX. ‡Molecular Microbiology Laboratory, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX. Address reprint requests to Veronica K. Goytia, MD, Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Room 302A, Houston, TX 77030. E-mail: [email protected]
1045-1870/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.spid.2006.08.003
revealed that the child lived in a house with his parents and family cat. The family had no recent history of travel, but relatives had stayed with the family 1 week earlier during an evacuation for Hurricane Rita, and the child’s grandfather had been ill with an upper respiratory tract infection. The infant was breastfed with formula supplementation, prepared with filtered water. Laboratory evaluation revealed a white blood cell count (WBC) of 5.4 ⫻ 103/L (20% neutrophils, 71% lymphocytes, and 8% monocytes), hemoglobin of 13.0 g/dL, hematocrit of 40 percent, and platelet count of 292 ⫻ 103/L. Blood urea nitrogen was 9 mg/dL, serum creatinine was 0.4 mg/dL, aspartate aminotransferase was 30 U/L, and alanine aminotransferase was 29 U/L. The cerebrospinal fluid (CSF) contained 1656 WBCs per cu mm (90% neutrophils, 6% lymphocytes), 57,045 red blood cells (RBCs) per cu mm, 1654 mg/dL protein, and less than 20 mg/dL glucose. The Gram-stained smear was negative. Because the diagnosis of neonatal meningitis was suspected, intravenous antibiotics were continued and a repeat CSF was obtained by lumbar puncture performed on the following day. It revealed 5312 WBC/cu mm (83% neutrophils, 6% lymphocytes), 6666 RBC/cu mm, 299 mg/dL protein, and 32 mg/dL glucose. The Gram-stained smear again was negative. The blood culture from the referring ED grew gram-negative bacilli after 24 hours of incubation, but the urine culture was negative. Bacterial cultures of blood, urine, and CSF; viral cultures of nasal secretions, stool, and CSF; and enterovirus polymerase chain reaction of the CSF were obtained at TCH. Latex agglutination studies for group B Streptococcus, Neisseria meningitidis, and Streptococcus pneumoniae were reportedly negative.
What is Your Diagnosis? For the diagnosis and treatment, refer to the Denouement on p. 225.
187
An Unusual Cause of Sepsis and Meningitis in a Neonate Veronica K. Goytia, MD,* Gail J. Demmler, MD,* Pia S. Pannaraj, MD,* Ruth Ann Luna, MS, C.L. Sp. (M.B.),†,‡ and James Versalovic, MD, PhD†,‡
A
26-day-old male infant presented to an Emergency Department (ED) in September, 2005, with a 1-day history of irritability, labored breathing, and decreased activity. He was a former 2547-g, 34 weeks of gestation premature infant born by spontaneous vaginal delivery to a 27-year-old rubellanonimmune woman whose pregnancy was complicated by prolonged rupture of membranes, treated with intrapartum intravenous ampicillin. Apgar scores were 8 at 1 minute and 9 at 5 minutes. A sepsis evaluation was performed because the infant had respiratory distress during the first day of life. Ampicillin and gentamicin were administered until bacterial culture results were sterile after 48 hours of incubation; phototherapy also was administered for physiologic jaundice. He was discharged home on day of life 7 and did well until his presenting illness. Physical examination was notable for fever (39°C) and periodic breathing accompanied by cyanosis. Supplemental oxygen was administered, and bacterial cultures of blood and urine were obtained. Doses of ampicillin, cefotaxime, and vancomycin were administered intravenously, and the infant was transferred to Texas Children’s Hospital (TCH) for further management. On arrival at TCH, the infant was alert but irritable and sucked his pacifier vigorously. His temperature was 39°C, heart rate was 170/min, respiratory rate was 60/min, blood pressure was 90/60 mm Hg, and oxygen saturations were 98 to 100 percent on room air. The physical examination was otherwise normal for his age. Social and exposure history
*Section of Infectious Diseases, Departments of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX. †Section of Infectious Diseases, Departments of Pediatrics Pathology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX. ‡Molecular Microbiology Laboratory, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX. Address reprint requests to Veronica K. Goytia, MD, Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Room 302A, Houston, TX 77030. E-mail: [email protected]
1045-1870/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.spid.2006.08.003
revealed that the child lived in a house with his parents and family cat. The family had no recent history of travel, but relatives had stayed with the family 1 week earlier during an evacuation for Hurricane Rita, and the child’s grandfather had been ill with an upper respiratory tract infection. The infant was breastfed with formula supplementation, prepared with filtered water. Laboratory evaluation revealed a white blood cell count (WBC) of 5.4 ⫻ 103/L (20% neutrophils, 71% lymphocytes, and 8% monocytes), hemoglobin of 13.0 g/dL, hematocrit of 40 percent, and platelet count of 292 ⫻ 103/L. Blood urea nitrogen was 9 mg/dL, serum creatinine was 0.4 mg/dL, aspartate aminotransferase was 30 U/L, and alanine aminotransferase was 29 U/L. The cerebrospinal fluid (CSF) contained 1656 WBCs per cu mm (90% neutrophils, 6% lymphocytes), 57,045 red blood cells (RBCs) per cu mm, 1654 mg/dL protein, and less than 20 mg/dL glucose. The Gram-stained smear was negative. Because the diagnosis of neonatal meningitis was suspected, intravenous antibiotics were continued and a repeat CSF was obtained by lumbar puncture performed on the following day. It revealed 5312 WBC/cu mm (83% neutrophils, 6% lymphocytes), 6666 RBC/cu mm, 299 mg/dL protein, and 32 mg/dL glucose. The Gram-stained smear again was negative. The blood culture from the referring ED grew gram-negative bacilli after 24 hours of incubation, but the urine culture was negative. Bacterial cultures of blood, urine, and CSF; viral cultures of nasal secretions, stool, and CSF; and enterovirus polymerase chain reaction of the CSF were obtained at TCH. Latex agglutination studies for group B Streptococcus, Neisseria meningitidis, and Streptococcus pneumoniae were reportedly negative.
What is Your Diagnosis? For the diagnosis and treatment, refer to the Denouement on p. 225.
187