neonatal case conference Flashcards
A 8 day old female infant born at 36 weeks gestation presented to the ED with feeding difficulties, intermittent cyanosis and apneic spells.
Initial Differential Diagnosis
see now
septic until proven otherwise
congenital heart defect
metabolic disease
- Sepsis
- Inborn error of metabolism (IEM)
- TORCH infections
- Congenital heart disease
- Hypoxic ischemic encephalopathy (get hypoxic in utero or during birth)
- Intracranial bleed
- Seizures
want to see red reflex in eyes
cataracts
retinoblastoma
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 O2and 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.
neonatal sepsis
apneic spells
chlamydia
lung infection
mycoplasma
neonatal sepsis
Definition-a clinical syndrome in the neonate characterized by systemic signs of infection with bacteremia (have to get cultures from blood) in the first month of life
- Meningitis is usually a sequelaof bacteremia and usually shares a common cause and pathogenesis
- Typical organisms include both gram (-) and gram (+) organisms
- Two patterns of disease-early and late onset
early onset neonatal sepsis
Time of onset
0-6days
Complicationsof pregnancy or delivery
+
Source of organism
Mother’s genital tract
Usual clinical presentation
Fulminant
Multisystem
Pneumoniafrequent
Mortalityrate
3-50%
2-40%
late onset neonatal sepsis
Time of onset
7-90 days
Complicationsof pregnancy or delivery
±
Source of organism
Mother’s genital tract; postnatal environment
Usual clinical presentation
Slowly progressiveorfulminant
Focal
Meningitis frequent
Mortalityrate
2-40%
mortality rate in neonatal sepsis
dpends on how much they see this problem
not a black and white problem til you get labs
Organisms Associated with Bacterial Sepsis
•Gram Positive organisms
Group B strep (GBS) (EOS and LOS)
Staphylococci aureus (LOC)
Coagulase negative staphylococcus (CoNS) (LOS)
Listeria monocytongenes
Organisms Associated with Bacterial Sepsis
•Gram Negative organisms
–E. coli (EOS and LOS)
–Haemophilus influenza
–Citrobacter
Fungi
Candida albicans
Clinical Signs of Bacterial Sepsis
Hyperthermia 51 Hypothermia 15 Respiratory distress 33 Apnea 22 Cyanosis 24 Jaundice 35 Hepatomegaly 33 Lethargy 25 Irritability 16 Anorexia 28 Vomiting 25 Abdominal distention 17
Clinical Signs of Bacterial Meningitis
Hypothermia or fever 62 Lethargy or irritability 52 Anorexia or vomiting 48 Respiratory distress 41 Bulging or full fontanelle 35 Seizures 31 Jaundice 28 Nuchal rigidity 16 Diarrhea 14
Diagnosis of Neonatal Sepsis
- Blood culture remains the gold standard
- Serum biomarkers can serve as an adjunct to culture based diagnosis
•The ideal marker
–Elevates early in the infectious process
–Stays elevated to allow appropriate sampling
–Have well defined values that differentiate infection from other entities
–A very high sensitivity and negative predictive value
C-Reactive Protein (CRP)
- Most commonly used biomarker
- Synthesized within 6 hours of exposure to an infectious process
- But takes up to 24 hours after onset of infection to become abnormal
- Is also elevated with trauma and ischemia
- A good indicator of neonatal sepsis??
- CRP does have high specificity between 93-100% meaning what??
Initial Management
- IV access (where?) (JUGULAR)
- Cultures
- Blood
- CSF? (late onset or meningitis, but early probably not bc going to use antibiotics)
- ABG
- CXR
- Glucose, electrolytes, BUN, creatinine (why?) (kidneys could ahve become damaged so dont want to put more on kidneys with abs)
- CRP
Initial Positive Results in our case
- CSF showed mononuclear pleocytosisof 330 cells/μL (shouldn’t have any)
- EEG showed multifocal epileptic potentials consistent with encephalitis
- CRP 5 mg/L (Normal
Initial treatment
- Empirical treatment with amoxicillin, gentamicin and acyclovir were started. A loading dose of phenobarbital was given. (bc of seizure)
- Despite antibiotic therapy the baby continues to deteriorate with tachycardia and increasing respiratory distress requiring intubation.
new studies in pt
varicella
herpes (neurologic problem with enephalitis with something in csf)
Echo and EKG Findings
- Echocardiography shows normal anatomy but severely reduced left ventricular contraction with an ejection fraction of 20%
- EKG shows ST depression in leads V1-V4.
- Troponin I level is reported at 10.2 μg/L with normal being less than 0.04
- PCR confirms the diagnosis
Final Diagnosis
Coxsackie B3 Myocarditis
Enteroviral Infections in the Newborn
- Among the most common viruses causing disease in humans with approximately 10-15 million symptomatic infections yearly in the USA
- Infections tend to have a seasonal pattern during summer and fall
- Illnesses range from a nonspecific febrile illness, mild URIs, self limiting gastroenteritis to myocarditis, hepatitis and encephalopathy
Enterovirus Neonatal Transmission
- Can be acquired antenatally, intrapartumand postnatally
* In-utero transmission can be by transplacentallyor by ascending infection
Clinical Features of Enterovirus Infection
- Associated with wide spectrum of signs and symptoms ranging from nonspecific febrile illness to fatal multisystem disease which is frequently called “Neonatal EnterovirusSepsis”
- 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
conjugated hyperbilirubinemia that doesnt go away
Back to the Case
- IV immunoglobulin was given
- Because of the decreased cardiac output and developing arrhythmias dopamine and milrinonewere started
- Over the next 48 hours the infant became refractory to amiodarone and electroconversionfor tachyarrhythmia
- ECMO (Extracorporeal Membrane Oxygenation) was started
ECMO was continued for 3 weeks with adequately decompressed heart chambers and without major bleeds or infection, however, left ventricular function did not improve and ECMO was withdrawn
Post-mortem examination showed diffuse inflammatory infiltrate of lymphocytes and extensive necrosis of the myocardium
