Index of Suspicion in the Nursery

Abstract

A female infant born at 36 weeks to a 25-year-old G2P2 mother by normal spontaneous vaginal delivery after an uncomplicated pregnancy, presents with respiratory distress and shock at 1 month of age. She has had 2 days of increased work of breathing with tachypnea and tracheal tugging; 2 weeks of cough, rhinorrhea, and nasal congestion; and currently an episode of cyanosis lasting 2 minutes. Weight gain has been appropriate since birth. On physical examination, rectal temperature is 34°C, heart rate is 126 beats per minute, blood pressure is 58/31 mm Hg, and oxygen saturation is 40% in room air. The patient has prolonged capillary refill indicative of poor peripheral perfusion, coarse breath sounds with rhonchi bilaterally, and hepatosplenomegaly. A chest radiograph shows diffuse coarse bilateral interstitial opacities with lucency over the right middle lobe (Fig 1). Figure 1. Chest radiograph demonstrating bilateral diffuse coarse interstitial markings with subsegmental left lower lobe opacity, right mid-lobe lucency, and small right-sided pleural effusion. Initial laboratory studies include an arterial blood gas with pH of 7.03, a Pco2 of 70 mm Hg, calculated bicarbonate of 18 mEq/L, and a base excess of –13; the patient’s serum lactate level was 6.7 mmol/L. The white blood cell count is 25.6 × 103/μL (25.6 × 109/L) with 41% neutrophils and 38% band forms. The C-reactive protein level is 107 mg/L. The serum total bilirubin is 1.3 mg/dL, alanine aminotransferase is 22 U/L, and aspartate aminotransferase is 88 U/L. Her prothrombin time (PT) is 31.9 seconds (international normalized ratio: 3.1), and activated partial thromboplastin time (aPTT) is 51.9 seconds. The cerebrospinal fluid cell count (CSF) cell count, differential, protein, and glucose are normal. Samples of blood, urine, CSF, and endotracheal tube aspirate were sent for viral and bacterial culture and polymerase chain reaction assays. Quantitative …