Index of Suspicion in the Nursery

Case Presentation

A 3-month-old Caucasian male is brought to the emergency department because of fever (temperature of 103°F [39.5°C]), repeated episodes of vomiting, and right-sided eye deviation for 24 hours. He was born at term via normal vaginal delivery after an uncomplicated pregnancy, and his birthweight was 2,930 g. Results of the mother’s routine prenatal tests were normal, including negative vaginal culture for group B Streptococcus. There were no perinatal complications, and the infant and mother were discharged from the hospital on the second postnatal day.

At 7 weeks of age, the infant was admitted for evaluation of a vesicular rash in the scrotal area and was diagnosed with cutaneous herpes (herpes simplex virus [HSV] type 1). The wound from his Jewish ritual circumcision involving oral suctioning (metzitzah b’peh) 10 days prior was believed to be the port of entry for the herpesvirus. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) test was negative for HSV, and he was discharged after receiving 14 days of intravenous acyclovir.

On physical examination today, the infant is pale, with sustained right-sided eye deviation. His temperature is 100.6°F (38.1°C), heart rate is 142 beats/min, respiratory rate is 30 breaths/min, blood pressure is 107/63 mm Hg, and oxygen saturation is 97% on room air. He has a full anterior fontanelle and pale, dry mucous membranes, and his capillary refill is 5 seconds. Chest, abdominal, genitourinary, and skin examination findings are unremarkable. During the physical examination, the right-sided eye deviation resolves, he has an episode of vomiting, becomes limp for seconds, and develops short runs of repetitive movements involving mostly the upper extremities and the eyes. His cardiorespiratory status remains stable. His serum glucose concentration is 92 mg/dL (5.1mmol/L).

Case Discussion

In an ill-appearing infant who presents with seizures, the differential diagnosis includes meningoencephalitis, metabolic abnormalities, trauma, intracranial bleeding, and …