Case 2: A 7-Day-Old African American Boy With Fever, Poor Feeding, and Lethargy

Abstract

A 39-week-old African American male neonate presents to the emergency department 7 days after birth for evaluation of fever, poor feeding, and lethargy. Prenatal and birth histories are unremarkable; however, an aunt with upper respiratory tract viral symptoms has been caring for the infant. Physical examination findings at presentation are normal, but the infant is febrile with a rectal temperature of 38.1°C (100.6°F). Evaluation in the emergency department includes blood, urine, and cerebrospinal fluid (CSF) analysis. Initial complete blood cell count is notable for a white blood cell count of 11,700/μL (11.7 × 109/L), hemoglobin level of 14.0 g/dL (140 g/L), hematocrit of 39.0% (0.39), and platelet count of 36 × 103/μL (36 × 109/L). CSF is notable for a white blood cell count of 14/μL (0% neutrophils, 45% lymphocytes, and 48% monocytes), a red blood cell count of 33/μL, and normal protein and glucose concentrations. The infant is admitted to the hospitalist service while receiving empiric ampicillin and cefotaxime. On hospital day (HD) 2, reverse transcriptase polymerase chain reaction is positive for enterovirus in the CSF; antibiotic treatment is discontinued. The infant remains febrile but is clinically well-appearing without signs of tachycardia, poor perfusion, hepatosplenomegaly, rash, or neurologic deficit. On HD 3, he deteriorates with hepatomegaly and abdominal distention. Further laboratory analysis is significant for elevated liver function test results (aspartate …