Sudden Onset of Neurologic Dysfunction in a Preterm Infant

Prenatal and Birth Histories

• Born to a 26-year-old woman with negative serologies

• Antepartum course was complicated by severe intrauterine growth restriction, absent end-diastolic flow velocimetery, and pregnancy-induced hypertension

• Delivery by cesarean section at 26 weeks’ gestation following preterm labor and suspected placental abruption

• Apgar score: 6 and 9 at 1 and 5 minutes, respectively. Birthweight, 510 g (3rd percentile).

• Soon after birth, the infant required intubation and surfactant administration. She received three 10% dextrose boluses (2 mL/kg each) for hypoglycemia. Blood glucose levels stabilized after a dextrose infusion via an umbilical venous catheter.

Initial Clinical Course

• Pulmonary insufficiency of prematurity requiring positive pressure ventilation. The infant also developed Klebsiella pneumonia at 32 weeks’ PMA requiring mechanical ventilation and antibiotics.

• At 38 weeks’ PMA, gastrostomy tube placement and Nissen fundoplication were performed due to poor oral motor skills and severe gastroesophageal reflux. No intraoperative complications were noted.

Presentation (Postoperative Day 4)

Postoperative course was remarkable for hypertension secondary to suspected pain and need for increasing ventilator support. On postoperative day 4, a complete blood cell (CBC) count showed a white blood cell (WBC) count of 17,700/μL (17.7 × 10⁹/L) with 35% bands. The hemoglobin and hematocrit were 15.8 g/dL (158 g/L) and 45.5%, respectively, with a platelet count of 238 × 10³/μL (238 × 10⁹/L). Although these laboratory findings raised a concern for an infection, the infant had unremarkable physical examination findings. Blood and urine culture were obtained (lumber puncture was deferred due to abdominal surgery) and the infant was started on broad-spectrum antibiotics (vancomycin, cefotaxime, and gentamicin).

Progression (Postoperative Day 5)

On postoperative day 5, an acute deterioration in the infant’s clinical status was noted.