Pediatrics Case Presentation
Transcript: Neonatal Case Presentation Andy Shi Huang, JMS Medical College of Georgia Day 0 Day 0 BG is a 0-day old girl infant born at gestational age 39w2d at 2:22 PM 8/26/20, SVD. She was born to a G1P1001 mother, GBS-/RPR-/chlamy-. Mother had recent HSV infection exposure on 8/19/20, and prescribed Valtrex 1 week ago when exposure was noted. Mother is homeless and on probation with an ankle bracelet for unknown reason at the time. Father is inconsistently in fights with mother in hospital and an unreliable story teller. Parents appear to lack resources available on eventual discharge. Perinatal complications: Perinatal Complications Chorioamnionitis Maternal fever Fetal tachycardia Prolonged delivery (stuck in canal at 9.5 cm for several hours) Newborn Pertinents Newborn APGAR: 7 & 9, AGA Infant had an initial rectal temp of 102, and 30 minutes later, 100.3. Decreased activity and weak cry, and obvious pallor/gray color. Infant had some grunting but no sign of respiratory distress. Clearly ill-appearing and MAP of 32, cap refill prolonged (6-7 seconds) Mildly decreased tone and weak suck Stark bruising noted on posterior scalp & caput succedaneum Coin-sized patch of denuded skin and two pustular lesions No overt appearance of vesicles or herpetic lesions Labs Labs Plan Plan Decision made to place IV and evaluate and treat for sepsis, NS bolus ordered to improve BP. Amp/gent started due to high suspicion for sepsis and may require prolonged treatment. Blood culture pending. CBC/CRP ordered. DFCS referral made. Addendum: after a second NS bolus, BP MAP increased to 44, color improved. Day 1-2 Day 1-2 Receiving Amp/Gent. PO feeding well. Scalp wound still with notable erythema on parietal/occipital scalp with coin-sized patch of denuded skin (with topical mupirocin applied)- smaller. No overt appearance of vesicles/herpetic lesions. Afebrile. Birth weight change percentage: 4%. Repeat Labs CBC, CRP, + CMP. Labs Labs #1 Plan Plan Given the elevated liver enzymes with slightly increase in CRP despite amp+gent x24 + mother's history of very recent HSV exposure/infection 1 week ago, clinical suspicion for neonatal HSV is increased. Performed lumbar puncture for HSV workup/cultures, gram stain, cell count, and differential, protein and glucose Acyclovir 20 mg/kg/dose IV q8 initiated. Continue maintenance IVF overnight to aid in BP (stable). Emphasized with MOB/FOB repeatedly about possible duration of treatment of 7, and up to 21 days depending on bacterial/HSV cultures. (Faced difficulties during discussion). HSV manifestations Evidence Neonatal HSV can be classified into three main categories, localized, CNS, and disseminated disease. In our case, we were worried about disseminated, which is approximately 1/4 of neonatal HSV disease, presenting with multiple organs involvement such as the hepatitis (with elevated liver transaminases). CNS is frequently involved (60-75%) through a hematogenously acquired meningoencephalitis. Neonates with disseminated HSV often present in the first week of life with nonspecific signs and symptoms of neonatal sepsis, including temperature dysregulation, apnea, irritability, lethargy, respiratory distress, abdominal distension, hepatomegaly, and ascites. Rarely, neonates with HSV infection may present with fever alone. The diagnosis of disseminated neonatal HSV disease often is delayed until the second week of life, awaiting the results of evaluation for bacterial sepsis. Day 2-3 Along with several NS boluses, LP was performed last night due to concerns for HSV. HSV skin/wound cultures x 6 was sent last night. Gram stain positive for GPC in clusters with 5-10 WBC per HPF. CSF HSV PCR pending. CSF culture pending. Day 2-3 Labs Labs Plan Continue amp/gent/acyclovir pending cultures. Due to clinical presentation of sepsis, infant will require a minimum of 7 days treatment. Will adjust based on culture results. Plan If HSV positive... HSV of Eyes All neonates with virologically-confirmed HSV should have an ophthalmologic examination in addition to conjunctival HSV cultures to evaluate for eye involvement. Presents as neonatal keratoconjunctivitis: conjunctival inflammation, typically occurring within the first 30 days of life. Complications range from mild hyperemia and scant discharge to permanent scarring and blindness. Typically present initially with unilateral or bilateral lid edema, moderate amount of conjunctival injection, and nonpurulent discharge. Consult is recommended as retinopathy, cataracts and chorioretinitis can develop. Ophthalmia Neonatorum Treatment Treatment Empirical treatment should be started soon after sending the culture and tapered once the final results are back. Acyclovir IV 45mg/kg/day plus vidarabine 3% ointment 5x/day for 14-21 days depending on presence or absence of CNS involvement. The outcomes for most neonates with conjunctivitis are good, particularly with interprofessional intervention and monitoring. Gichuhi S et al. Risk factors for neonatal conjunctivitis