Neonatal Emergencies 2

Question 1

Listeria monocytogenes (4)

Answer 1

1. Gram positive motile bacterium
2. Acquired by the newborn – transplacentally
   * Ascending infection with ROM
   * Upon exposure during vaginal delivery
3. Relatively rare (newborns/immunocompromised)
4. Isolated in soil, and the environment but primary route of acquisition is through food products (mom ingests something that is contaminated with listeria, she can fight it off but it will affect the fetus) – ask mom what she’s been eating
   i. Soft cheese
   ii. Unpasteurized milk products
   iii. Undercooked meat
   iv. Cold cuts (Listeria likes cold)
   v. Hot dogs

Question 2

Key questions for listeria (6)

Answer 2

1. Contaminated food ingestion – known?
2. Travel?
3. Diet?
4. Maternal influenza-like symptom?
5. Deliver ?
6. Meconium? Foul smelling green-brown discharge? → think Listeria

Question 3

Listeria Clinical Presentation (5)

Answer 3

EOS sepsis so early presentation of the newborn!!

Variable symptoms:
i. Respiratory distress

ii. Temperature instability
iii. Poor feeding
iv. Lethargy/irritability

v. Granulomatosis infantisepticum rash (distinct/hallmark!!)
* Erythematous rash
* Small, pale nodules or granulomas noted

Question 4

Listeria Work-Up (4)

Answer 4

a. Blood culture
b. CSF
c. Respiratory culture
d. Culture rash if it’s there

Question 5

Listeria Tx/Management (3)

Answer 5

1. Antibiotics
   * Ampicillin+Aminoglycoside
   * NOT susceptible to cephalosporins; do not use them if suspicious of listeria!
2. Temperature stability
3. Respiratory status

Question 6

Late Onset Sepsis (3)

Answer 6

1. Day 7-90 (89)
2. GBS meningitis
3. Community acquired

Question 7

LOS Etiologies (6)

Answer 7

1. Staph pneumoniae, Neisseria meningitis
   * Ampicillin and Cefotaxime – because meningitis is often a component of LOS
2. Meningitis
   * Higher in first month of life than at any other age
3. GBS, Gram negative enteric bacilli
4. Enterococcus species
5. Staph Aureus
6. Fungal

Question 8

LOS Risk Factors (5)

Answer 8

1. Hospitalization – Coexisting conditions
2. Prematurity
3. Immature immune system

Post-natal Exposures:

1. Community
2. Siblings
3. Postnatal maternal risks
   a. What is she eating?
   b. Has she been breastfeeding? Etc
4. Maternal infections
   * GBS unknown status or inadequately treated

Question 9

LOS Work-Up and Dx (6)

Answer 9

1. Blood Culture (remember that growth takes ~48 hours)
2. CSF growth
   * DO LP WITH LOS!!!
3. CBC with differential
4. Chest X-ray if respiratory symptoms
5. Urine culture
6. ** Requires growth of organism – typically takes 48 hours **

Question 10

LOS Treatment (Agents (2) and Duration of therapy (3))

Answer 10

Antimicrobial agent:

1. Vancomycin
2. Aminoglycoside + Ampicillin

Duration of Therapy:

1. 14 days for Listeria or GBS
2. 3 weeks for gram negative bacilli – more difficult to eradicate from CSF
3. Some treat for 2 weeks from negative culture

Question 11

CMV Common Manifestations (5)

Answer 11

a. Petechiae
b. Blueberry muffin rash
c. LBW
d. HSM
e. Jaundice at birth

Question 12

CMV Dx (2)

Answer 12

1. Isolation of CMV form urine in 1st 3 weeks of life is most reliable
2. IgM antibodies to CMV

Question 13

Parvovirus B19 General Info (6)

Answer 13

1. Single stranded RNA virus
2. Causative agent of Fifth disease (Erythema Infectiosum/slapped cheek)
3. Causes aplastic crisis in individuals with hemolytic anemia as erythrocyte progenitors are targeted.
   a. Transmission from mother to fetus is a problem because it crosses the placenta
   b. Breaks down erythrocytes and causes severe anemia
   c. Erythrocyte progenitors are targeted and they are unable to regenerate
4. Infects and lyses erythroblasts
5. Spread by the respiratory route, 60-70% of the population is eventually infected.
6. 50% of women of childbearing age are susceptible to infection.

Question 14

Parvo B19 Presentation (8)

Answer 14

1. Pallor; Due to the severe anemia
2. Respiratory distress
3. Hydrops fetalis; For severe cases of parvo; usually detected in utero because they are incredibly edematous & have poor growth
4. Prematurity
5. IUGR
6. Myocarditis
7. Murmur may be present
8. Signs of heart failure – severe anemia

Question 15

Parvo B19 Dx (3)

Answer 15

1. Clinical presentation & history of mom
2. Serologies IgG, IgM
3. PCR

Question 16

Parvo B19 Management (3)

Answer 16

1. Admit and stabilize – inpatient management
2. IVIG
   * Not significant data but has been shown to work in severe cases
3. PRBC transfusion

Question 17

Zika as RNA Flavivirus (4)

Answer 17

1. Related to dengue and yellow fever
2. Part of a larger group of viruses “arborviruses” (for arthropod borne)
3. Transmitted to humans via bite of infected mosquito (arthropod)
4. Falviviruses are enveloped viruses that contain nonsegmented single-strand positive RNA genomes

Question 18

Zika Transmission (6)

Answer 18

a. Aedes aegypti mosquito primary vector
b. Lay eggs in water containers around the home
c. “cluster bite”
d. Nervous feeders (bite 5-10 people a day)

e. Peak feeding daytime
i. Very different than malaria mosquito that only bites once and usually bites at night

f. Not many in the US – but can be imported via cargo
i. Water
ii. Hitch-hike on luggage

Question 19

Congenital Zika Syndrome (5)

Answer 19

1. Recently recognized pattern of congenital anomalies associated with Zika infection during pregnancy
2. Severe microcephaly- resulting in partially collapsed skull
3. Decreased Brain tissue – with brain damage
4. Drop out of neuronal cells
5. Kills these cells- zika receptor is found on placenta and many of the neuro progenitor cells (that develop the brain later on)
   * Causes high risk of developing this syndrome

Question 20

Zika Presentation (6)

Answer 20

1. Damage to the back of the eye – with specific scarring pattern
2. Limited range of joint motion (clubfoot)
3. Hypertonia
4. First trimester seems to be the worst exposure time – but this is not certain
5. Shedding of virus in cervix
6. Transmission through breastmilk

Question 21

Infants should be tested for Zika if… (4)

Answer 21

1, THEY HAVE MICROCEPHALY AND WERE BORN TO A WOMAN WHO TRAVELED TO OR RESIDED IN AN AREA WHERE ZIKA IS KNOWN WHILE PREGNANT

2. BORN TO A MOTHER WHO IS POSITIVE FOR ZIKA
3. MOTHER IS INCONCLUSIVE FOR ZIKA
4. Tested after birth within 2 days of life ideal

Question 22

Zika Testing (6)

Answer 22

1. Send Blood and Urine (Order – ZIKA RNA NAT TEST)
2. Notify your local DOH
3. ABR (hearing)
4. Eye exam within 1 month of life
5. Comprehensive Neurological Assessment
6. Head Ultrasound (HUS)

Question 23

Neonatal Infection Follow-Ups (5)

Answer 23

1. PNP should evaluate the following closely after a diagnosed neonatal infection:
2. Growth – Remember to plot each visit! (and don’t forget the Head Circumference)
3. Developmental milestones and skeletal assessment (CP increased incidence with meningitis and severe EOS)
4. Hearing evaluation (remember hearing impairment and loss is a major complication of neonatal sepsis – either from the infection itself or the antibiotics!)
5. Refer to ophthalmology (visual loss – invasion of bacteria or virus in many of presented neonatal infections; GBS, CMV, Zika)