Index of Suspicion in the Nursery

Abstract

A 2-week-old Hispanic male infant is admitted with a 1-day history of subjective fever, nonbilious vomiting, decreased oral intake, and lethargy. The physical examination is normal other than two small pustules, one on the cheek and the other on the scalp; both are sent for culture. He was born at 33 5/7 weeks’ gestation to a 27-year-old G8-P6-5-1-1-6 woman. The mother had prenatal care starting at approximately 4 months of gestation that was complicated by premature and prolonged rupture of membranes (22 hours) with purulent amniotic fluid. Her laboratory evaluation included the following: blood group AB positive, rapid plasma reagin nonreactive, hepatitis B negative, HIV negative, and urine drug screen negative. Her group B streptococcus, chlamydia, gonorrhea, and rubella screens are unknown. The mother received azithromycin and metronidazole during labor and delivery. The infant was delivered via emergent cesarean delivery for chorioamnionitis. His Apgar scores were 4 and 8 at 1 and 5 minutes, respectively. The infant had neither a feeding problem nor apnea/bradycardia and received ampicillin and gentamicin intravenously for 7 days due to the maternal chorioamnionitis. His blood culture was negative. He was discharged home at 9 days of age. When he arrives back at 2 weeks of age, a complete evaluation for neonatal sepsis is initiated and herpes simplex virus infection is suspected. He receives empiric treatment with acyclovir, vancomycin, and cefotaxime. ### Admission Laboratory Data CBC: white blood cell (WBC) counts 6,400/mm3; Hgb, 13.7 g/dL; Hct, 40.9%; and platelets, 409,000/mm3. WBC counts differential: segmented forms, 55%; bands, 4%; lymphocytes, 26%; and monocytes, 14%. Urinalysis: specific gravity, 1.015; negative glucose, small amount of blood, trace protein, no WBCs/high power field, 0 to 2 red blood cells/high power field. CSF: glucose, 34 mg/dL; protein greater than 460 mg/dL; red blood cell count, 26,200/mm3; WBC count, 100/mm …