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Fever and fussiness in a 17-day-old infant
CASE STUDY
Fever and Fussiness in a 17-Day-Old Infant Susan H. Wootton, MD and Coburn H. Allen, MD
A
17-day-old Hispanic male presented to the Emergency Department of Ben Taub General Hospital (Houston, TX) with a history of several days of congestion and rhinorrhea and of 1 day of fussiness, decreased oral intake, and warmth to touch. The infant was the 8-lb, 5-oz product of a full-term gestation born by spontaneous vaginal delivery. His neonatal course was complicated by physiologic jaundice. The mother had received prenatal care and had a vaginal culture that was negative for group B Streptococcus. The infant lived at home with his parents, maternal grandparents, and three siblings, aged 4 years, 2 years, and 16 months. One week before the patient’s hospitalization, the three siblings were ill with upper respiratory tract symptoms. On arrival to the emergency center, the infant was mottledappearing. His temperature was 103.7° F, pulse rate was 142 beats per minute, respiratory rate was 40 breaths per minute, and blood pressure was 89/60 mm Hg. His weight was 4 kg (50%), length 49 cm (10%), and head circumference 37 cm (50%). He was fussy, crying throughout the examination, but consolable at rest. His anterior fontanel was full, his neck was stiff, and he had a positive Brudzinski sign. White patches Department of Pediatrics, Infectious Diseases Section, Baylor College of Medicine, Houston, Texas. Address reprint requests to Susan H. Wootton, MD, Department of Pediatrics, Infectious Diseases Section, Feigin Center, Suite 1150, 6621 Fannin Street, MC 3-2371, Houston, TX 77030-2399. E-mail: swootton@ bcm.tmc.edu
1045-1870/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.spid.2005.12.002
consistent with oral thrush were present on his oral mucosa. His extremities were cool, and his capillary refill was less than 3 seconds. The remainder of his physical examination was normal. The initial management included an intravenous normal saline bolus (20 mL/kg); collection of blood and cerebrospinal fluid cultures, and intravenous administration of ampicillin (100 mg/kg); cefotaxime (50 mg/kg), and gentamicin (2.5 mg/kg). Laboratory evaluation at admission revealed a white blood cell count of 6400/mm3 (57% polymorphonuclear leukocytes, 32% lymphocytes, 9% monocytes, and 2% eosinophils), hemoglobin 16.4 g/dL, hematocrit 47.4 percent, and platelet count 383,000/mm3. The serum sodium was 138 mmol/L, potassium 5.9 mmol/L, chloride 112 mmol/L, and bicarbonate 19 mmol/L. Urinalysis was within normal limits. The cerebrospinal fluid contained 2050 white blood cells/mm3 (90% polymorphonuclear cells, 3% lymphocytes, 2% monocytes, and 5% eosinophils), 150 red blood cells/ mm3, 313 mg/dL of protein, and 16 mg/dL of glucose. Cerebrospinal fluid gram stain revealed many white blood cells and moderate numbers of gram-negative coccobacilli. The patient was transferred to the pediatric intensive care unit for further monitoring.
What Causative Organisms Would You Consider? Please see page 148 for the Denouement.
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Fever and Fussiness in a 17-Day-Old Infant Susan H. Wootton, MD and Coburn H. Allen, MD
A
17-day-old Hispanic male presented to the Emergency Department of Ben Taub General Hospital (Houston, TX) with a history of several days of congestion and rhinorrhea and of 1 day of fussiness, decreased oral intake, and warmth to touch. The infant was the 8-lb, 5-oz product of a full-term gestation born by spontaneous vaginal delivery. His neonatal course was complicated by physiologic jaundice. The mother had received prenatal care and had a vaginal culture that was negative for group B Streptococcus. The infant lived at home with his parents, maternal grandparents, and three siblings, aged 4 years, 2 years, and 16 months. One week before the patient’s hospitalization, the three siblings were ill with upper respiratory tract symptoms. On arrival to the emergency center, the infant was mottledappearing. His temperature was 103.7° F, pulse rate was 142 beats per minute, respiratory rate was 40 breaths per minute, and blood pressure was 89/60 mm Hg. His weight was 4 kg (50%), length 49 cm (10%), and head circumference 37 cm (50%). He was fussy, crying throughout the examination, but consolable at rest. His anterior fontanel was full, his neck was stiff, and he had a positive Brudzinski sign. White patches Department of Pediatrics, Infectious Diseases Section, Baylor College of Medicine, Houston, Texas. Address reprint requests to Susan H. Wootton, MD, Department of Pediatrics, Infectious Diseases Section, Feigin Center, Suite 1150, 6621 Fannin Street, MC 3-2371, Houston, TX 77030-2399. E-mail: swootton@ bcm.tmc.edu
1045-1870/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.spid.2005.12.002
consistent with oral thrush were present on his oral mucosa. His extremities were cool, and his capillary refill was less than 3 seconds. The remainder of his physical examination was normal. The initial management included an intravenous normal saline bolus (20 mL/kg); collection of blood and cerebrospinal fluid cultures, and intravenous administration of ampicillin (100 mg/kg); cefotaxime (50 mg/kg), and gentamicin (2.5 mg/kg). Laboratory evaluation at admission revealed a white blood cell count of 6400/mm3 (57% polymorphonuclear leukocytes, 32% lymphocytes, 9% monocytes, and 2% eosinophils), hemoglobin 16.4 g/dL, hematocrit 47.4 percent, and platelet count 383,000/mm3. The serum sodium was 138 mmol/L, potassium 5.9 mmol/L, chloride 112 mmol/L, and bicarbonate 19 mmol/L. Urinalysis was within normal limits. The cerebrospinal fluid contained 2050 white blood cells/mm3 (90% polymorphonuclear cells, 3% lymphocytes, 2% monocytes, and 5% eosinophils), 150 red blood cells/ mm3, 313 mg/dL of protein, and 16 mg/dL of glucose. Cerebrospinal fluid gram stain revealed many white blood cells and moderate numbers of gram-negative coccobacilli. The patient was transferred to the pediatric intensive care unit for further monitoring.
What Causative Organisms Would You Consider? Please see page 148 for the Denouement.
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