Visual Diagnosis: Sepsis, Respiratory Distress, and a Persistent Right Lung Opacification in a Newborn

Abstract

1. Himalee Sabnis, MD* 2. Beena G. Sood, MD, MS* 3. Mark Zilberman, MD* 4. Cristie Becker, MD† 1. *Carman and Ann Adams Department of Pediatrics 2. †Department of Pediatric Radiology, Wayne State University, Children's Hospital of Michigan, Detroit, Mich A 20-year-old primigravida woman delivers a term female infant weighing 3,112 g via caesarean section under spinal anesthesia. The mother's antenatal test results are unremarkable, including a negative group B beta-hemolytic Streptococcus (GBS) screen at 33 to 34 weeks’ gestation. Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. Physical examination results are normal. Four hours after delivery, the infant develops tachypnea, grunting, and “blue” lower extremities. Supplemental oxygen is provided, blood and urine cultures are performed, and empiric treatment with intravenous ampicillin and cefotaxime is initiated. A chest radiograph reveals a normal cardiac silhouette with bilateral perihilar “streaking” of the lungs. Complete blood count reveals leukopenia, with an absolute neutrophil count of 200 cells/mm3 and thrombocytopenia. At 12 hours of age, the blood culture is positive for gram-positive cocci, later identified as GBS. A lumbar puncture yields xanthochromic cerebrospinal fluid (CSF) that contains 9 red blood cells and 52 white blood cells, of which 97% are mononuclear. CSF glucose concentration is 50 mg/dL (2.8 mmol/L) (blood glucose, 93 mg/dL [5.2 mmol/L]) and protein concentration 191 mg/dL. GBS antigen is detected in both the CSF and urine. At 18 hours of age, the infant becomes mottled in appearance, develops severe respiratory acidosis, and requires assisted ventilation. A chest radiograph at this time reveals patchy infiltrates consistent with pneumonia. Fluid resuscitation and alkali therapy are initiated for hypotension and metabolic acidosis, respectively. At 20 hours of age, the baby is transferred to a level III neonatal intensive care unit for management. On admission to the intensive care nursery, physical examination reveals an intubated infant who has a hyperdynamic precordium and good air entry in both lungs. Admission chest radiograph shows …