Index of Suspicion in the Nursery

Presentation

A 4.1-kg, 10-day-old, term Hispanic male infant presents to the emergency department (ED) with multiple episodes of paroxysmal jerky movements, irritability, and an episode of cyanosis. Parents report decreased responsiveness and oral intake 3 days before presentation. Patient was born at 40.1 weeks to a G2P1001 via cesarian delivery for arrest of dilatation. The Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. Prenatal course and delivery history are unremarkable, including negative maternal serologies and group B Streptococcus (GBS) culture.

While in the ED, the patient has 5 episodes of tonic-clonic seizures, with dropping oxygen saturation to 70%, and is intubated for airway protection. Vital signs reveal temperature of 101.5°F, heart rate of 170 beats per minute, respiratory rate of 42 breaths per minute, and blood pressure of 90/60 mm Hg. Physical examination reveals markedly decreased responsiveness with no other positive findings. A full sepsis evaluation is performed including cultures of blood, urine, cerebrospinal fluid (CSF), and computed tomography (CT) of the head. Lorazepam is started for seizures. Empiric broad-spectrum antimicrobial therapy including ampicillin, gentamicin, cefotaxime, and acyclovir is initiated. The infant is admitted for further diagnostic and therapeutic management.