Case 1: An Infant with Arm Swelling and Nodules

Abstract

A male neonate is born via spontaneous vaginal delivery to a 28-year-old primiparous woman at 39 2/7 weeks of gestation after an uncomplicated pregnancy. Labor is complicated by prolonged fetal heart rate decelerations, but the mother declines a cesarean section and vacuum extraction is initially unsuccessful. At birth the neonate is apneic but maintains a heart rate greater than 100 beats/min throughout the resuscitation. He requires intubation for persistent apnea 4 minutes after birth. His Apgar scores are 2, 3, 5, and 5 at 1, 5, 10, and 20 minutes, respectively. His physical examination on admission to the NICU is significant for diffuse hypotonia, lethargy, and absence of primitive reflexes. His arterial blood gas measurement 1.5 hours after birth shows a pH of 7.32, Pco2 of 32 mm Hg, and base deficit of 9. A blood culture specimen is collected and he starts empiric treatment with ampicillin and gentamicin. The infant is transferred to a tertiary care NICU for therapeutic hypothermia and has moderate encephalopathy on admission. He has a fluctuant, boggy mass over his occipital skull and undergoes noncontrast head computed tomography, which shows a large subgaleal hemorrhage, skull fracture, and small ventricles concerning for cerebral edema. A significant drop in his hematocrit is noted, and he receives transfusions of packed red blood cells and fresh frozen plasma. He requires a dopamine infusion and stress-dose hydrocortisone to maintain age-appropriate blood pressures. Electroencephalography (EEG) shows electrographic and clinical seizure activity, which is …