Case 2: Multiple Cranial Nerve Palsies in a Neonate with a History of Perinatal Asphyxia

Case Presentation

A singleton term male neonate is born of a nonconsanguineous marriage with no significant antenatal history and a birthweight of 2,600 g via cesarean section. He does not cry immediately after birth and is resuscitated with positive pressure ventilation for 2 minutes. The Apgar scores are 3 at 1 minute and 7 at 5 and 10 minutes. The extramurally delivered newborn is brought to the NICU for postresuscitation care. On initial examination, the neonate is encephalopathic with altered sensorium, hypotonia, and poor respiratory efforts. The heart rate is 110 beats/min with good volume pulses and a capillary refilling time of less than 3 seconds. Features of multiple right-sided lower motor neuron type of cranial nerve palsies (cranial nerves V, VII, IX, X) are seen on clinical examination. These include deviation of the angle of mouth to the left side, obliteration of nasolabial fold and failure to close the eyelid on the right side, abnormal gag reflex, and pooling of secretions. In view of poor breathing efforts, the newborn undergoes intubation and is started on conventional mechanical ventilation. Cord arterial blood gas reveals a pH of 7.25 and a base deficit of −5 mmol/L, which is normal. Routine supplementation with intravenous vitamin K is given. A provisional diagnosis of perinatal asphyxia with hypoxic-ischemic encephalopathy (HIE) with brainstem involvement is made.

Progression