Neonatal Cases - SRS

Question 1

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

Answer 1

1. •Sepsis
2. •Inborn error of metabolism (IEM)
3. •TORCH infections
4. •Congenital heart disease
5. •Hypoxic ischemic encephalopathy
6. •Intracranial bleed
7. •Seizures

Question 2

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?

Answer 2

Neonatal Sepsis

Blood culture is the gold standard.

Serum biomarkers are an adjuct for diagnostics.

Question 3

What is the definition of neonatal sepsis?

Answer 3

•a clinical syndrome in the neonate characterized by systemic signs of infection with bacteremia in the first month of life

Question 4

What is a common sequela of bacteremia in neonatal sepsis?

Answer 4

Meningitis. Usually shares a common cause and pathogenesis

Question 5

Neonatal sepsis can arise from gram + or - organisms and has what patterns of disease?

Answer 5

Early onset

Late onset

Question 6

What is the timeline for early onset?

Answer 6

0-6 days

Question 7

What is the time line for late onset?

Answer 7

7-90 days

Question 8

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?

Mortality rate?

Answer 8

1. Fulminant
2. Multisystem
3. Pneumonia frequently

3-50% mortality rate

Question 9

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?

Mortality rate?

Answer 9

1. Slowly progressive or fulminant
2. focal meningitis is frequent

2-40% mortality rate

Question 10

What are some gram positive organisms associated with bacterial sepsis?

Identify which are associated with early onset (EOS) and late onset (LOS)

Answer 10

Group B strep (GBS) (EOS and LOS)

Staphylococci aureus (LOC)

Coagulase negative staphylococcus (CoNS) (LOS)

Listeria monocytongenes

Question 11

What are some gran negative organisms associated with bacterial sepsis?

Answer 11

–E. coli (EOS and LOS)

–Haemophilus influenza

–Citrobacter

Fungi

Candida albicans

Question 12

What are the clinical signs of bacterial sepsis?

Answer 12

1. Hyperthermia
2. Jaundice
3. Respiratory Distress
4. Hepatomegaly
5. Anorexia
6. Lethargy
7. Vomiting
8. Cyanosis
9. apnea
10. Abdominal distension
11. Irritability
12. Hypothermia

Question 13

What are the clinical signs of bacterial meningitis?

Answer 13

1. Hypothermia or fever
2. lethargy or irritibility
3. anorexia or vomiting
4. respiratory distress
5. Bulging or full fontanelle
6. Siezures
7. JAundice
8. Nuchal rigidity
9. Diarrhea

Question 14

Although the gold standard for diagnosis of neonatal sepsis, there are problems with the blood culture process. What are they?

Answer 14

Takes too long to culture, typically 48 hrs or more. Patient may not have that long.

Question 15

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?

Answer 15

Takes up to 24 hours to become abnormal

Also elevated in trauma and ischemia thus not a good indicator of neonatal sepsis.

Question 16

What are the components of the initial management of neonatal sepsis?

Answer 16

• IV access - peripheral or central line
• Cultures
• Blood
• CSF? - probably not unless late onset.
• ABG
• CXR
• Glucose, electrolytes, BUN, creatinine (why?)
• CRP

Question 17

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?

Answer 17

amoxicillin, gentamicin and acyclovir

Question 18

•Despite antibiotic therapy the baby continues to deteriorate with tachycardia and increasing respiratory distress requiring intubation.

What new studies should be done?

Answer 18

Echocardiogram

EKG

Question 19

Chest X ray reveals pulmonary edema What organ might be infected?

Answer 19

Heart

Question 20

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?

Answer 20

•Illnesses range from a nonspecific febrile illness, mild URIs, self limiting gastroenteritis to myocarditis, hepatitis and encephalopathy

Question 21

What are the most common presenting features of enterovirus infection? How about other less common features?

Answer 21

• 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