A 8 day old female infant born at 36 weeks gestation presented to the ED with feeding difficulties, intermittent cyanosis and apneic spells.
Differential? Give seven
- •Inborn error of metabolism (IEM)
- •TORCH infections
- •Congenital heart disease
- •Hypoxic ischemic encephalopathy
- •Intracranial bleed
A 8 day old female infant born at 36 weeks gestation presented to the ED with feeding difficulties, intermittent cyanosis and apneic spells. Infant was born to a G1, P0 28 year old female by normal vaginal delivery without complication. Membranes ruptured 11 hours before delivery. The mother had an uneventful pregnancy with appropriate prenatal care including negative GBS screening. The infant’s weight, length and head circumference were all within the 25-50th percentile. Appropriate newborn screening was performed before discharge on day 3. The infant was breast fed and eating well at discharge. The infant was active and in no distress, skin was free of lesions, HEENT all normal for age, lungs were clear to auscultation and heart had RRR without murmurs. Palpation of the abdomen revealed no masses or organomegaly. Inspection of the back revealed no abnormalities. Genitalia were appropriate for age. The infant appeared ill with moderate respiratory distress with mild subcostal retractions and a dusky blue color of the lips and nail beds that was intermittent. Episodic apneic spells were observed that responded to administration of O2 and stimulation. Tachycardia and tachypnea were present. Auscultation of the lungs revealed crackles but no regions of consolidation. Heart auscultation revealed no murmurs. Palpation of the abdomen revealed no masses or organomegaly.
What is the initial diagnosis?
Plan going forward?
Blood culture is the gold standard.
Serum biomarkers are an adjuct for diagnostics.
What is the definition of neonatal sepsis?
•a clinical syndrome in the neonate characterized by systemic signs of infection with bacteremia in the first month of life
What is a common sequela of bacteremia in neonatal sepsis?
Meningitis. Usually shares a common cause and pathogenesis
Neonatal sepsis can arise from gram + or - organisms and has what patterns of disease?
What is the timeline for early onset?
What is the time line for late onset?
Early onset neonatal sepsis is typically associated with complications of pregnancy or delivery, and the organism originates in the mother's genital tract. What is the usual clinical presentation?
- Pneumonia frequently
3-50% mortality rate
Late onset neonatal sepsis may or may not have complications of pregnancy/delivery, and can originate from the mother's genital tract OR the environment. What is the usual clinical presentation?
- Slowly progressive or fulminant
- focal meningitis is frequent
2-40% mortality rate
What are some gram positive organisms associated with bacterial sepsis?
Identify which are associated with early onset (EOS) and late onset (LOS)
Group B strep (GBS) (EOS and LOS)
Staphylococci aureus (LOC)
Coagulase negative staphylococcus (CoNS) (LOS)
What are some gran negative organisms associated with bacterial sepsis?
–E. coli (EOS and LOS)
What are the clinical signs of bacterial sepsis?
- Respiratory Distress
- Abdominal distension
What are the clinical signs of bacterial meningitis?
- Hypothermia or fever
- lethargy or irritibility
- anorexia or vomiting
- respiratory distress
- Bulging or full fontanelle
- Nuchal rigidity
Although the gold standard for diagnosis of neonatal sepsis, there are problems with the blood culture process. What are they?
Takes too long to culture, typically 48 hrs or more. Patient may not have that long.
CRP is the most commonly used biomarker and is synthesized within 6 hours of exposure to an infectious process. How long does it take to become abnormal? Is it a good indicator or neonatal sepsis?
Takes up to 24 hours to become abnormal
Also elevated in trauma and ischemia thus not a good indicator of neonatal sepsis.
What are the components of the initial management of neonatal sepsis?
•IV access - peripheral or central line
•CSF? - probably not unless late onset.
•Glucose, electrolytes, BUN, creatinine (why?)
Patients intial results reveal...
•CSF showed mononuclear pleocytosis of 330 cells/µL
•EEG showed multifocal epileptic potentials consistent with encephalitis
•CRP 5 mg/L (Normal < 10 mg/L)
What should initial treatment include?
amoxicillin, gentamicin and acyclovir
•Despite antibiotic therapy the baby continues to deteriorate with tachycardia and increasing respiratory distress requiring intubation.
What new studies should be done?
Chest X ray reveals pulmonary edema What organ might be infected?
PCR confirmed the diagnosis of Coxsackie B3 myocarditis. Enteroviral infections are very common and hace a seasonal pattern. What do the illnesses range from as far as clinical picture?
•Illnesses range from a nonspecific febrile illness, mild URIs, self limiting gastroenteritis to myocarditis, hepatitis and encephalopathy
What are the most common presenting features of enterovirus infection? How about other less common features?
•Most common presenting features include fever, irritability, poor feeding and lethargy
•A nonspecific rash is seen in approximately half of infants infected
•Approximately half have evidence of hepatitis or jaundice. Hepatomegaly may be present but splenomegaly is rare