Case 1: A premature infant with apneic spells

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A female infant was born at 25 weeks, three days’ gestational age with a birth weight of 820 g. The issues encountered during her stay at a tertiary-level neonatal intensive care unit (NICU) included prematurity, respiratory distress syndrome, chronic lung disease (CLD), patent ductus arteriosis, a single course of treatment with indomethacin, hypoglycemia, two red blood cell infusions, grade 1 intraventricular hemorrhage, mild periventricular leukomalacia and retinopathy of prematurity. Her respiratory history included three doses of surfactant, high-frequency oscillation and eventual extubation on day 7 of life to nasal prong continuous positive airway pressure. No systemic steroids were administered for extubation. On day 9 of life, the patient was started on inhaled nebulized budesonide 500 μg twice daily. She was initially on high-flow oxygen, and was then maintained on low-flow oxygen and, eventually, room air. On day 59 of life, the patient was transferred from the tertiary-level NICU to a secondary-level NICU (level 2C). Budesonide was weaned over a seven-day period. During this period, she became unwell, with increasing signs of respiratory distress, apneic spells and a urine sample obtained by catheterization positive for Enterococcus species and Escherichia coli. Urosepsis was suspected and treatment with intravenous fluids and intravenous antibiotics was commenced. The infant received 25 mL/min supplementary oxygen for 48 h and was then transitioned to room air. Fluid boluses for hypotension were not required, and the infant eventually recovered from the acute episode. Blood and cerebrospinal fluid cultures were negative for bacterial growth. A laboratory test was conducted due to clinical suspicion and revealed the underlying diagnosis.