Septic Workup Research Articles

Stüve-Wiedemann syndrome with a novel variant in the LIFR gene: A case report.

Stüve-Wiedemann syndrome (SWS) is a rare, severe autosomal recessive disorder (#OMIM 601559) caused by pathogenic variants in the LIFR gene. It is characterized by skeletal dysplasia and dysautonomia and carries a high mortality rate in infancy, which decreases significantly after the age of 2. Detailed case descriptions enhance understanding of this rare condition. We report a male, full-term infant born to consanguineous Yemeni parents with no family history of genetic disorders. Prenatal ultrasound revealed short, bowed long bones suggestive of skeletal dysplasia. At 12 hours of age, the infant developed respiratory distress, poor sucking, and an agitated cry. At 48 hours, he experienced unexplained hyperthermia, and a comprehensive septic workup was negative. Initial findings included generalized hypotonia, hyporeflexia, and dysmorphic features (micrognathia, camptodactyly, short, and bowed limbs). Radiographic imaging revealed skeletal abnormalities. Whole exome sequencing identified a novel homozygous pathogenic variant in the LIFR gene (c.2257dup p.(Arg753Lysfs*20)), confirming the diagnosis of autosomal recessive SWS type 1. The infant was admitted to the neonatal intensive care unit, received nasal oxygen support, and was managed with orogastric tube feeding due to poor sucking and swallowing. At 5 months, the infant remains dependent on orogastric tube feeding, with less frequent hyperthermic episodes. SWS is a rare genetic disorder with a wide phenotypic spectrum. Early recognition and multidisciplinary management are crucial to addressing the high mortality risk associated with dysautonomia in infancy. Case reports of novel variants contribute to a deeper understanding of SWS and highlight the importance of tailored clinical care for improved outcomes.

Implementation of INEWS to Improve Patient Outcomes in a Community Hospital

Abstract Background It is imperative to identify at risk older patients with clinical deterioration as soon as possible. The Irish National Early Warning System (INEWS)1 is used to detect clinical deterioration at an early stage based on each patient's vital sign records. It can then initiate a communication mechanism between nurses and doctors to enable early patient care. Data on the effectiveness of the INEWS in patients admitted to community rehabilitation wards, the barriers and difficulties encountered during implementation, are still scarce, despite the development and implementation in acute settings. There are not enough standardised tool available to identify patients' deterioration for community hospitals. Methods This pilot quality improvement programme was conducted in a community hospital's rehabilitation section. Data were gathered seven weeks after the deployment of INEWS and fourteen weeks before. Issues were studied to determine the underlying cause, created a driver diagram to comprehend the factors that lead to unexpected outcomes, educated and gathered feedback from the clinical care teams involved, measured adherence to the INEWS during the six-week pilot project implementation period, and assessed results by looking back at the deteriorating patient data and INEWS compliance using Plan, Do, Study, Act cycles. Results During the pre-INEWS introduction phase (14 weeks), there were 11.9 events per week (7.8 events with infection or septic workups, 9.6 events with onsite management, 1.0 acute care transfers, 0.28 per week unexpected deaths). In the post-INEWS piloting phase (6 weeks), there were 3.6 events per week (2.5 infection or septic workup, 1.8 onsite management and 1.1 acute care transfers per week with no unexpected deaths). Conclusion Conclusion Early detection and rapid management through the INEWS can enhance patient care; however, increased stakeholder engagement in escalation response may enhance patient outcome in resource limited community setting. Reference https://www2.healthservice.hse.ie/organisation/qps-improvement/deteriorating-patient-improvement-programme-partnership-dpipp/

Atypical Presentation of Meningoencephalitis in an Infant Caused by Meningococcemia and Complicated by Ventriculitis with Bilateral Extra Axial Septated Collection

Background: The diagnosis of meningitis in the infancy period is a challenging. Clinical evaluation and high index of suspicion with early empirical treatment guidelines continue to evolve and support physician efforts to decrease the morbidity and mortality associated with pediatric meningitis. Case report: We report a case of a previously healthy 2-month-old male who presented with excessive crying, preceded by subjective fever and watery diarrhea, for one day without any other symptoms. Parents gave multiple antipyretic doses at home for irritability which might mask his fever. The patient was tachycardic with an unremarkable physical exam. Full septic work-up done after stabilization of the patient and empirical antibiotics started. His blood culture grew Neisseria meningitides which caused meningoencephalitis and ventriculitis with bilateral extra-axial collection, the patient was in septic shock with multiple organ dysfunction. Conclusion: Meningococcal meningitis in the neonatal and infancy periods remains a serious health threat with high morbidity and mortality. This case report urges the physician to keep a high index of suspicion by taking detailed history and frequent assessment in each suspected cases as the clinical presentations, signs and symptoms in the infancy period are not specific nor classic to guide the physician.

Implementation of early warning system in the clinical teaching unit to reduce unexpected deaths

BackgroundEarly detection of patients with clinical deterioration admitted to the hospital is critical. The early warning system (EWS) is developed to identify early clinical deterioration. Using individual patient’s vital sign...

A CASE SERIES ON VARIED CLINICAL PRESENTATION IN LEIGHS SYNDROME IN A TERTIARY CARE HOSPITAL

Background:Leigh syndrome (LS) is a hereditary neurometabolic disease, also known as subacute necrotizing encephalomyelopathy, and was described by the British neuropathologist and psychiatrist Denis Leigh in 1951. It is a neurodegenerative disease with variable symptoms that occurs due to a mitochondrial dysfunction caused by a hereditary genetic defect, associated with bilateral central nervous system lesions. Although it is a rare disease, with an approximate incidence of 1: 40,000 live births, it is the most frequent mitochondrial disease in the first year of life. Clinical Scenario: Case 1 Baby Nikshitha, a 6-and-a-half-month old female child born to a multigravida mother in a non-consanguineous marriage with previous 2 abortions and 1 intrauterine death. The baby was born through LSCS (oligohydramnios) and cried immediately at birth with a weight of 2.5kgs with uneventful antenatal periods.Excessive Vomiting x 1 month, increased over 5 days, Inability to gain weight over the past 3 months, Abnormal Posturing - 2 days prior to admission Mri Brain: Symmetric areas of altered intensity in bilateral caudate nucleus relatively sparing Globus pallidi showing diffusion restriction. Clinical Scenario: Case 2 Baby of suhasini, a 3 months old female child born to a primi mother in a non-consanguineous marriage with previous 1 sibling death. The baby was born through NVD and cried immediately at birth with a weight of 2.5kgs with uneventful antenatal periods.Child presented to the hospital at 3months of life with the chief complaints of - FEVER x 4 days, Noisy breathing since 4 days, Abnormal Posturing – since yesterday nightInitial Septic workup to rule out meningitis – NORMAL. ABG done in view of failure to thrive with recurrent vomiting – Metabolic Acidosis.Mri Brain: Symmetric areas of altered intensity in bilateral caudate nucleus relatively sparing Globus pallidi showing diffusion restriction. No blooming to suggest haemorrhage or calcification. Myelination is consistent with age Clinical Scenario: Case 3 Shobhakumari, 2Y old female child born to a multigravida mother in a non-consanguineous marriage with h/o sibling death at 5 years of age (leighs disease). The baby was born through NVD and cried immediately at birth with a weight of 2.5kgs with uneventful antenatal periods.Child presented to the hospital at 2 years with the chief complaints of - Excessive Vomiting since 6daysInability to gain weight over the past 3 months MRI brain :T2/Flair hyperintense signal with restricted diffusion in deep grey matter of b/l cerebellar hemisphere and periaqueductal grey matter of midbrain caudate nucleus and putamen Clinical Scenario: Case 4 B/o Afreen 4 year male born to a primi mother through normal vaginal delivery in a non-consanguineousmarriage with birth weight of 2.7 kg . Child presented to a hospital with History of regression of milestones and rhythmic repetitive movement of upper limb since 15 months of age. Serum lactate was high and MRI brain showed symmetrical B/l T2/FLAIR caudate and putamen nucleus hyperintensity with restriction on DW1 images Discussion:Several studies showed significant heterogeneity in the clinical findings of Leigh syndrome. Sofou K et al., revealed in a study that 69% of the cases presented before 2 years of age, while three patients presented with ataxia or seizures at 8,10 and 21 years of age. Conclusion:The diagnosis of Leighs disease should be considered in appropriate clinical and laboratory settings whenever symmetrical hypo densities are encountered in the putamen and midbrain on.

Elevated Urinary Hepcidin Level and Hypoferremia in Infants with Febrile Urinary Tract Infection: A Prospective Cohort Study.

To evaluate the kinetics of serum and urinary hepcidin levels along with anemia-related parameters during the infection course of infants with febrile urinary tract infection (UTI), we enrolled febrile infants aged one to four months in this prospective study. Febrile patients with UTI were allocated into Escherichia coli (E. coli) or non-E. coli groups according to urine culture results. Septic workup, blood hepcidin, iron profile, urinalysis, and urinary hepcidin-creatinine ratio were collected upon admission and 3 days after antibiotic treatment. In total, 118 infants were included. On admission, the febrile UTI group showed a significant reduction in serum iron level and a significant elevation of urinary hepcidin-creatinine ratio compared to the febrile control counterpart. Moreover, urinary hepcidin-creatinine ratio had the highest odds ratio, 2.01, in logistics regression analysis. After 3 days of antibiotic treatment, hemoglobin and the urinary hepcidin-creatinine ratio were significantly decreased. Patients with an E. coli UTI had a significantly decreased urinary hepcidin-creatinine ratio after 3 days of antibiotics treatment, whereas the non-E. coli group showed insignificant changes. Our study suggested that the urinary hepcidin-creatinine ratio elevated during acute febrile urinary tract infection and significantly decreased after 3 days of antibiotics treatment, especially in E. coli UTI.

Clinical Cases of Refractory Hyperlactatemia in Pediatric Inpatients.

Case 1: A 16-year-old male with no prior hospitalizations was admitted for urgent neurosurgical management of a craniopharyngioma, a benign brain tumor that grows adjacent to the pituitary gland. He underwent right transcortical craniotomy for tumor resection with right frontal external ventricular drain insertion. His postoperative course was complicated by central diabetes insipidus, a condition of antidiuretic hormone deficiency and subsequent polyuria, and a fluctuating level of consciousness preventing him from feeding orally. Nasogastric feeds were started four days postoperatively. While alert, he drank to thirst. Gastric absorption was likely impaired due to constipation, ileus, and dependent edema. Due to his central diabetes insipidus, he had polyuria with urine output >5 mL/kg/h while a steady state of vasopressin, then desmopressin, was achieved. In the first 11 days postoperative, he lost 8% of his body weight (4.2 kg), even with fluid replacements to a neutral balance. His lactate began climbing with levels peaking at 7.1 mmol/L (normal for age: 1.2 to 2.5 mmol/L; Fig. 1, A). Vital signs were stable with no evidence of end organ hypoperfusion. Septic workup was negative. An echocardiogram showed normal cardiac function. His fluid status was neutral, with urinary losses replaced. Liver function was normal with no hepatocellular injury. There were no new medication exposures, and no current medications were known to cause hyperlactatemia. Given his poor nutritional intake, absorption and ongoing polyuria, an alternative cause of his hyperlactatemia was considered.

The full blood count in screening asymptomatic infants for early-onset sepsis: A cross-sectional study.

The full blood count (FBC) is commonly measured as part of a partial septic work-up in asymptomatic infants at increased risk of early-onset neonatal sepsis (EOS). To determine the impact of FBC parameters on infants' subsequent management a retrospective cross-sectional study was performed. Infants, born at ≥34 weeks gestation, asymptomatic at birth, undergoing a partial septic work-up and receiving prophylactic antibiotics due to increased risk of EOS in a single centre over a 2-year period, were included. The primary outcome measure was frequency of FBC result impacting on duration of antibiotic therapy. Secondary outcome measures included frequency of FBC parameters outside of the reference range and incidental diagnoses. In total, 16 726 live-born infants were delivered during the study period. A total of 802 (4.8%) were included. Thirteen infants (1.6%) received a prolonged course of antibiotics due to suspicion for EOS. Two of these infants had elevated white cell counts. All had normal neutrophil counts. In no case did the FBC result influence the decision to prolong the antibiotic course. In a cohort of 802 infants, asymptomatic at birth and at increased risk of EOS, the FBC result did not impact on the decision to prolong the course of antibiotics for suspicion of EOS.

RF07 | PSUN359 Alpelisib-induced Diabetic Ketoacidosis

Abstract Background Alpelisib is an oral α-specific phosphatidylinositol 3-kinase (PI3K) inhibitor use in combination with fulvestrant to treat postmenopausal women with HR+/HER2−, PIK3CA-mutated, advanced or metastatic breast cancer that has acquired resistance to endocrine-based therapy. (1)Alpelisib interferes with the PI3K/Akt signalling pathway resulting in impaired peripheral glucose uptake, increased liver glycogenolysis, loss of beta-cell mass and insulin secretion dysfunction(2). Hyperglycemia is a frequent adverse effect of alpelisib but diabetic ketoacidosis (DKA) is considered a rare occurrence. We describe a patient without a previous history of diabetes who developed DKA after 2 months on alpelisib.Clinical caseA 81 year-old woman with metastatic ER+ PR – Her2 - breast cancer, presented with a 1 week history of nausea, vomiting, and polyuria. Her hemoglobin A1C was 5.5% on two separate occasions last year. She had started alpelisib at 300 mg/day 7 weeks prior to presentation. She presented with a blood glucose (BG) of 659 mg/dL, anion gap of 21, serum bicarbonate 17 mmol/L, beta-hydroxybutyrate 3.82 mmol/L (normal < 0.27 mmol/L), serum osmolarity 319 mOsm/kg, serum creatinine 2.83 mg/dL (baseline 1.38 mg/dL), C-peptide 4.3 ng/mL (normal 1.1–4.4 ng/mL), negative GAD-65 antibodies and Islet Antigen 2 antibodies, septic workup were non-revealing, leading to the diagnosis of alpelisib-associated DKA. Alpelisib was held, and she was treated with intravenous insulin and hydration. DKA resolved in 12 hours, however, she had persistent hyperglycemia. She was started with insulin regimen of 0.2 units/kg and discharged with Humalog 75/25 5 units twice daily. Conclusion Patients with no pre-existing history of diabetes mellitus can also be at risk for DKA which may develop within weeks to months of initiation of alpelisib. Risk factors for development of DKA are yet to be identified, but would be useful to help tailor frequency of BG monitoring. This warrants further research. The hyperglycemic effects of alpelisib appear to be reversible upon drug discontinuation, however when DKA is the presenting syndrome, insulin therapy is indicated. Reference André F, Ciruelos E, Rubovszky G, Campone M, Loibl S, Rugo HS, Iwata H, Conte P, Mayer IA, Kaufman B, Yamashita T, Lu YS, Inoue K, Takahashi M, Pápai Z, Longin AS, Mills D, Wilke C, Hirawat S, Juric D; SOLAR-1 Study Group. Alpelisib for PIK3CA-Mutated, Hormone Receptor-Positive Advanced Breast Cancer. N Engl J Med. 2019 May 16;380(20): 1929-1940. doi: 10.1056/NEJMoa1813904. PMID: 31091374. Nguyen P, Musa A, Samantray J. Alpelisib-Induced Diabetic Ketoacidosis. Cureus. 2021 May 1;13(5): e14796. doi: 10.7759/cureus.14796. PMID: 34084688; PMCID: PMC8166359. Presentation: Saturday, June 11, 2022 1:36 p.m. - 1:41 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Procalcitonin Testing With Secondary Coinfection in Patients With COVID-19.

BackgroundThe coronavirus disease (COVID-19) virus has caused millions of deaths. It is difficult to differentiate between pure viral COVID-19 pneumonia and secondary infection. Clinicians often use procalcitonin (PCT) to decide on empiric antibiotic therapy.MethodologyWe performed a retrospective study of patients admitted with COVID-19 between January 1st, 2020, and June 30th, 2020. Patient demographics, clinical findings, and laboratory findings with a focus on PCT levels were recorded. Coinfection was considered if clinicians ordered a septic workup (urine, blood, and respiratory cultures) or if the physicians started or escalated antimicrobial therapy. PCT levels on the day of culture and daily for the next three days were recorded. Significant PCT change was defined as a decrease in PCT levels of >50% from the initial elevated PCT level.ResultsIn total, 143 (59.8%) patients had one secondary infection. These included pulmonary infections (118, 49.4%), blood infections (99, 41.4%), and urine infections (64, 26.8%). Many patients had more than one documented positive culture: respiratory system and blood together in 80 (33.4%) patients, sputum and urine in 55 (23.1%) patients, and urine and blood in 46 (19.2%) patients. Out of the 143 patients with a positive culture, PCT was abnormal on the day of positive culture in 93 (65.5%), while PCT was abnormal in 64 out of 96 on the day of negative culture (66.7%) (p = 0.89). Individual analysis for PCT levels of respiratory cultures showed out of 118 positive sputum cultures, 86 (72%) had abnormal PCT on the day of culture. PCT in positive versus negative cultures was not significantly different, with median PCT (interquartile range, IQR) of 1.66 (6.61) versus 1.03 (2.23) (p = 0.172). For blood cultures, out of 99 positive blood cultures, 73 (73%) had abnormal PCT levels on the day of the culture. PCT in positive versus negative cultures was significantly elevated, with a median of 1.61 (5.97) vs. 0.65 (1.77) (p < 0.001). For urine, out of 64 positive cultures, 41 (64.1%) had abnormal PCT levels on the day of the culture. PCT in positive versus negative cultures was not significantly different, with a median of 0.71 (2.92) vs. 0.93 (4.71) (p = 0.551). To observe the change in PCT after culture, PCT values for the next three days after culture were analyzed. We found that patients with positive cultures had higher PCT levels than those with negative cultures. There was no significant improvement over the following three days. Patients with abnormal PCT on the day of the suspected infection had a longer length of stay in the hospital, with a median (IQR) of 23.9 days (3.16) vs. 16.9 days (2.18) (p = 0.021).ConclusionsSecondary coinfections in patients with COVID-19 infections are not associated with PCT elevation on the day of suspected secondary infection. However, most patients with bacteremia had a significant elevation of PCT on the day of bacteremia before collection and reporting of positive culture. Patients with abnormal PCT levels on the day of suspected infection had a longer hospital stay than patients with normal PCT levels. Subsequent testing of PCT in patients showed no significant improvement in PCT.

Congenital brucellosis associated with subsequent Klebsiella pneumoniae co-infection in a premature neonate: A rare case report

We report a case of congenital brucellosis subsequently associated with Klebsiella pneumoniae infection in a Saudi preterm neonate. A girl born with severe respiratory distress was admitted to a neonatal intensive care unit. Laboratory examinations revealed thrombocytopenia and slight leukocytosis. Her mother was a confirmed case of brucellosis. Initial blood culture confirmed the diagnosis of infection, and the baby was treated empirically with rifampicin, gentamicin, and ciprofloxacin. Follow-up revealed that her general condition was gradually improved. On day 27, the baby deteriorated, showing abdominal distension and signs of sepsis and requiring intubation. Rifampicin was replaced by amikacin. A septic workup showed a normal total leukocyte count, with 68.3% neutrophils, decreased platelet count, and increased C-reactive protein level. Blood culture and sensitivity testing reported multidrug-resistant K. pneumoniae susceptible to amikacin and resistance to gentamicin, ciprofloxacin, and beta-lactam antibiotics. The baby remains critically ill, showing a poor treatment response with rapid deterioration, and arrested on day 33. Concomitant bacterial infections might explain signs of sepsis and respiratory distress among neonates with congenital brucellosis. Accurate and early diagnosis, parental history, and adequate treatment are associated with the prognosis of congenital brucellosis and other related bacterial infections.

Pediatric Benign Neutropenia: Assessing Practice Preferences in Canada.

Pediatric benign neutropenia is a self-limited condition with a benign clinical course. An approach to this condition is not well-defined in the literature. Our objective was to use a case-based survey to elucidate trends in the diagnosis and management of benign neutropenia among pediatric hematology/oncology practitioners in Canada. We received 46 completed surveys (response rate 66%). At initial presentation with fever and neutropenia, 67% of respondents recommended partial septic workup but 11% recommended no investigations. Nearly 70% recommended admission for empiric intravenous antibiotics, while 24% would discharge home without antibiotics. In a patient with fever and known neutropenia, respondents were more likely to pursue outpatient antibiotic therapy. For investigation of chronic neutropenia, most respondents (60%) do not use antineutrophil antibody testing. Common indications for bone marrow biopsy were severe infection, prolonged neutropenia, or before initiating granulocyte colony stimulating factor. Indications for granulocyte colony stimulating factor were based on severity and frequency of infection. Most respondents (84%) would not recommend antibiotic prophylaxis. Results demonstrate the considerable variability in management of benign neutropenia among pediatric hematology/oncology practitioners in Canada and highlight the need for prospective studies to establish diagnostic criteria for benign neutropenia and evaluate management of fever in this population.

Pseudomembranous Enteritis Presenting as SAIO Mimicking a Case of Small Bowel Crohn’s

Background: Pseudomembranous colitis (PMC) is a manifestation of severe colonic disease that is usually associated with Clostridium difficile infection but associated small bowel involvement is rare and presentation as obligating enteropathy is even rarer. Aims and Methods: 21 years old medical student residing in south India presented with history of recent onset of vomiting of 2-3 weeks, mild abdominal distention and occasional colic for 1 week and mild degree fever for 2 days. She gives h/o recurrent lower abdominal pain and bloody stools of 9 months for which she underwent upper and lower GI scopes and was diagnosed with Biopsy proven IBD-UC - Montreal L2 with mild to moderate severity and was well controlled with 5 ASA. She was asymptomatic until presentation. Investigations s/o Elevated TC with neutrophilic predominance, CRP ,Anaemia, Hypoalbuminemia ,vit D def. She was started on Iv antibiotics and mesacol along with supportive mediations, Septic workup, AxR, was Wnl. Colonoscopy suggestive of Inflammatory Pancolitis with some whitish exudates in R colon? PMC,UC-EIS 9, UGI scopy s/o D2D3 narrowing with superficial ulcerations, Stools C/s, CD toxins/GDH. Based on this her immunosuppressants were titrated and modified along with treatment for PMC were initiated. She improved and was discharged after 10 days. Biopsy suggestive of UC associated Entropathy with f/s/o Pseudo- membraneous enteritis. along with focal enhanced gastritis with a single periglandular granuloma. CTenterography done after 2 weeks were essentially normal. Currently she is nearly asymptomatic on azathioprine, steroids and metronidazole is doing well. Results:PMC Enterocolitis needs to be thought as a differential of patient presenting with proximal bowel disease with IBD-UC. Though rare can present as a close mimicker of CD. Conclusion: PMC is a rare cause of Obstructive enteropathy. PMC needs to thought as a differential in a patient with proximal bowel involvement in a patient with Ulcerative colitis. Keywords: PMC, Entero Colitis, Abdominal Pain

Tick Paralysis Case Series: An 11-Year Institutional Case Series.

The aims of the study were to identify and to describe cases of pediatric tick paralysis presenting to an emergency department in southern Louisiana during an 11-year period. We conducted a retrospective chart review of patients aged 0 to 18 years with a diagnostic code of toxic effect of venom, tick-borne viral encephalitis, Guillain-Barré syndrome, acute infective polyneuritis, or abnormality of gait from July 2005 to June 2016. Data were collected on visit month, patient age, race and sex, tick's attachment site, location of tick removal, symptoms and length of symptoms, initial diagnosis, time to appropriate diagnosis, and hospital length of stay. Nine patients aged 2 to 10 years presented with lower limb weakness and varying degrees of upper extremity ataxia or paralysis, areflexia, dysarthria, diplopia, or petechia. Five cases were accurately and rapidly diagnosed; 4 cases involved a delay in accurate diagnosis. Treatment of the misdiagnosed cases ranged from septic workup to neurologic workup, including magnetic resonance imaging. The tick was discovered by the patients' relative in 4 cases, by a primary care or emergency care physician at another facility in 3 cases, and by 1 of our emergency care physicians in 2 patients. The incidence of tick paralysis in southern Louisiana is unknown. However, our case series indicates that it is likely higher than expected. Although most cases in our facility were quickly diagnosed and treated through tick removal, delayed diagnosis results in unnecessary tests, procedures, and medical costs. All of our cases fully recovered after tick removal.

Beta-lactamase-negative ampicillin-resistant Haemophilus influenzae type b meningitis in partially immunized immunocompetent child: a\xa0case report

IntroductionHaemophilus influenzae is a Gram-negative coccobacillus that can cause many different kinds of infection, ranging from mild ear infection to life-threatening diseases like epiglottitis and meningitis. Encapsulated type b Haemophilus influenzae was most commonly responsible for Haemophilus influenzae meningitis in children before introduction of Haemophilus influenzae conjugate vaccine. None or partially immunized children are acquiring meningitis owing to resistant strains of Haemophilus influenzae, namely beta-lactamase-negative ampicillin-resistant strain.Case presentationWe reported the case of a 2-year-old Emirati boy who presented to our emergency department with fever, diarrhea, vomiting, and fluctuating levels of consciousness. He was developmentally normal with no significant past medical history, except he was partially immunized. Earlier, he had been treated for acute gastroenteritis with intravenous fluids and antiemetics in another hospital and was discharged. His parents escorted him to our emergency department as he became very drowsy. Examination revealed that he was in septic shock. He was immediately treated with oxygen, intravenous antibiotics, and fluids after performing septic workup. He was then shifted to intensive care unit. Blood culture and cerebrospinal fluid Gram stain confirmed diagnosis of beta-lactamase-negative ampicillin-resistant Haemophilus influenzae. He was started on intravenous ceftriaxone, acyclovir, and dexamethasone. He still spiked fever after 1 week. Therefore, ceftriaxone was replaced by meropenem. He recovered well with no sequelae.ConclusionThis case highlights atypical presentation of life-threatening illness along with microbial resistance that had positive outcome due to timely diagnosis and aggressive management by a multidisciplinary team.

PREVALENCE AND OUTCOME OF THROMBOCYTOPENIA AND ITS CORRELATION WITH CRP IN NEONATAL INTENSIVE CARE UNIT

Introduction: Neonatal thrombocytopenia, one of the most common hematological abnormalities in neonates particularly in premature and sick neonates. The aim of this study to study the prevalence and outcome of Thrombocytopenia and its correlation with CRP in the neonatal intensive care unit. Objectives: 1. To nd the prevalence of Thrombocytopenia in the Neonatal intensive care unit in King George Hospital. 2. Factors that predisposing to Thrombocytopenia in neonates 3. Outcomes of thrombocytopenia in neonates. 4. Correlation of thrombocytopenia with the C-reactive protein (CRP) in neonates. Materials And Methods: It is a cross -sectional study in 80 Newborns less than or equal to 28 days admitted in NICU, king George hospital, Visakhapatnam from JANUARY 2019 to JUNE 2020 over period of 18 months. Data is collected from the medical records. Results: The prevalence of thrombocytopenia in this study is 40% with early-onset thrombocytopenia being 65% whereas, that of late-onset thrombocytopenia is 35% ,strong assosciation is found between thrombocytopenia and sepsis ,with mild to moderate variety being (86.4%) and (40%) of severe thrombocytopenia group. Of 80 newborns ,90% of severely thrombocytopenic group have positive CRP, whereas it is 40.9% in the mild to moderate group and 1.4% in normal group.40% of severe thrombocytopenic group had elevated PT, APTT, INR. There was higher proportion of bleeding (45.5%) in severe thrombocytopenia group. gastrointestinal bleeding constituted for 36.4% and intracranial bleeding 2.1% . Conclusion: Positive septic workup is signicantly association with thrombocytopenia, CRP was signicantly association with thrombocytopenia in this study

Clinical characterization of benign enterovirus infection in neonates.

Enteroviruses is a group of positive single-stranded RNA viruses ubiquitous in the environment, which is a causative agent of epidemic diseases in children and infants. But data on neonates are still limited. The present study aimed to describe the clinical characteristics of enterovirus infection in neonates and arise the awareness of this disease to general public.Between March 2018 and September 2019, data from all of the neonates diagnosed with enterovirus infection were collected and analyzed from neonatal intensive care unit of Zhangzhou Hospital in Fujian, China.A total of 23 neonates were enrolled. All of them presented with fever (100%), and some with rashes (39.1%). The incidence of aseptic meningitis was high (91.3%), but only a small proportion (28.6%) presented with cerebrospinal fluid (CSF) leukocytosis. The positive value for nucleic acid detection in CSF was significantly higher than throat swab (91.3% vs 43.5%, P = .007). Five of the infected neonates presented with aseptic meningitis (23.8%) underwent brain magnetic resonance imaging examination and no craniocerebral injuries were found. Subsequent follow-ups were performed in 15 of them (71.4%) and no neurological sequelae was found.Aseptic meningitis is a common type of enterovirus infection in neonates with a benign course. Nucleic acid detection of CSF has an important diagnostic value. Febrile neonates would be suggested to screen for enterovirus infection in addition to complete septic workup. An unnecessary initiation or earlier cessation of antibiotics could be considered in enterovirus infection, but that indications still need further studies to guarantee the safety.

Life-Threatening VIPoma Crisis in an Immunocompromised Patient

Background: Vasoactive intestinal peptide-secreting tumors (VIPoma) are rare neuroendocrine tumors (NETs) that present with a triad of profuse watery diarrhea, hypokalemia, and achlorhydria. The resulting renal impairment, electrolytes and acid-base imbalances pose a high risk of morbidity and mortality. We describe a case of life-threatening VIPoma crisis in an immunocompromised patient. Clinical Case: A 64-year-old man was intubated after he was brought in unconscious with tachypnea. Upon review, he had experienced persistent watery diarrhea for the past 6 months, with a weight loss of 18 kg. He had severe hypokalemia (potassium 1.9 mmol/L, n= 3.5-5.0), metabolic acidosis (blood gases pH 6.927, bicarbonate 4.8 mmol/L, base excess -25.9 mmol/L), and acute kidney injury (urea 47.9 mmol/L, creatinine 980umol/L). He continued to have electrolyte imbalances and acidosis due to persistent diarrhea, despite hydration and dialysis support. His biohazard screening results were positive for human immunodeficiency virus (HIV), with a CD4 count of 101 cells/µl. He was given courses of antibiotics for treating pathogenic infections; however, his septic workups were negative for infection, including HIV-related opportunistic infections. Later, pancreatic CT revealed a well-defined heterogeneously enhancing pancreatic head mass, size 6.8x5.2x7.5 cm. Further laboratory investigations confirmed the diagnosis of VIPoma, with elevated VIP levels (1600 pg/ml, n < 75). Eventually, subcutaneous octreotide was started, with resolution of the diarrhea and normalization of his electrolytes and renal function. After a 6-week hospital stay, he was discharged well with monthly octreotide and initiated on antiretroviral therapy (ART). After 3 months of ART, his CD4 count improved, and he remained diarrhea-free with octreotide. He is scheduled for tumor debulking surgery. Conclusion:This case highlights the importance of having a clinical suspicion of NETs, especially in immunocompromised patients. Further investigations and imaging studies to rule out noninfectious pathologies should be considered in patients who respond poorly to standard therapy. In VIPoma, somatostatin analog is an antisecretory treatment and it is highly effective for controlling diarrhea. High-dose octreotide up to 1500 µg/day has previously been studied for treatment of refractory diarrhoea in the setting of HIV infection² and it has been found to be helpful in reducing stool volume and frequency. Lastly, delays in the diagnosis and treatment of VIPoma in immunocompromised patients can be fatal. References1/ Hoffland J., Kaltsas G., de Herder W. Advances in the Diagnosis and Management of Well-Differentiated Neuroendocrine Neoplasms. Endocrine Reviews, Volume 41, Issue 2, April 2020, Pages 371-403.2/ Farthing MJ. Octreotide in the treatment of refractory diarrhoea and intestinal fistulae. Gut 1994;35:S5-10.

Passenger Lymphocyte Syndrome in a Pediatric Lung Transplant Recipient with Previous Bone Marrow Transplantation

Introduction Passenger lymphocyte syndrome (PLS) is a rare complication following solid organ transplantation (SOT). It consists of immune-mediated hemolysis due to antibodies produced by donor B-lymphocytes against recipient red blood cells [1]. Incidence across all SOT is as low as 0.5% in adults, with the highest rates being in lung and heart [2,3,4]. There have been no cases reported in children post-lung transplantation to our knowledge. Case Report A 12-year-old female received a double lung transplantation for bronchiolitis obliterans due to graft versus-host disease (GHVD). She had undergone allogeneic BMT 6 years prior for myelodysplastic syndrome (MDS). Her post-BMT course was complicated by lung, skin, and gastrointestinal GVHD. Lung transplant was uncomplicated: with donor blood group O+, recipient blood group A+, and crossmatch negative. On post-operative day 13, there was an acute drop in hemoglobin: from 131 g/L day 7, to 87 g/L day 13, to 66 g/L the same day. Septic workup was negative. Direct antiglobulin test was positive. Hemolysis markers were present with high LDH, high unconjugated bilirubin, and low haptoglobin. Eluate test was positive for anti-A1 antibody, consistent with a diagnosis of PLS. She received donor-type (O+) red cells, and was given IVIG 600 mg/kg for hypogammaglobulinemia. Hemoglobin recovered after day 21. Given her BMT history, concern around recurrent MDS was also raised. A chimerism study was sent on day 22 for this with the added benefit of examining for circulating lung-donor lymphocytes. No MDS was revealed. FISH revealed all cells were chromosomally XX (recipient had received BMT from a female donor), indicating no persistent circulating lung-donor lymphocytes since lung donor was male. Summary We report PLS following lung transplant in a 12-year-old post-BMT. Risk factors included minor ABO mismatch and organ type transplanted, with a high lymphocyte burden in lungs compared to other organs [3,4]. It is unclear whether prior allogeneic BMT and GVHD were added risk factors. Given higher PLS rates post-BMT [5], one could postulate that this may have also predisposed to PLS in this case. Albeit self-limiting, transfusion with donor blood group is necessary to prevent further hemolysis. Finally, a chimerism study for MDS has the added benefit of searching for lung-donor lymphocytes, if still present in circulation.

Factors associated with neurodevelopment in preterm infants with systematic inflammation

BackgroundSeveral studies have suggested that adverse neurodevelopment could be induced by systemic inflammation in preterm infants. We aimed to investigate whether preterm infants with systemic inflammation would have impaired neurodevelopment and which biomarkers and neurophysiologic studies during inflammation are associated with poor neurodevelopment.MethodsThis prospective cohort study enrolled infants born before 30 weeks of gestation or with birth weight < 1250 g. Infants were grouped according to the presence of systemic inflammation: Control (no inflammation, n = 49), I (systemic inflammation, n = 45). Blood and cerebrospinal fluid samples for markers of brain injury and inflammation were collected and amplitude-integrated electroencephalography (aEEG) was performed within 4 h of septic workup. We evaluated aEEG at 35 weeks postmenstrual age (PMA), head circumference at 36 weeks PMA, and brain MRI at discharge. The Bayley Scales of Infant and Toddler Development III (Bayley-III) was performed at a corrected age (CA) of 18 months.ResultsThe I group had more white matter injuries (2 vs. 26.7%, Control vs. I, respectively) at the time of discharge, lower brain functional maturation (9.5 vs. 8), and smaller head size (z-score − 1.45 vs. -2.12) at near-term age and poorer neurodevelopment at a CA of 18 months than the control (p < 0.05). Among the I group, the proportion of immature neutrophils (I/T ratios) and IL-1 beta levels in the CSF were associated with aEEG measures at the day of symptom onset (D0). Seizure spike on aEEG at D0 was significantly correlated with motor and social-emotional domains of Bayley-III (p < 0.05). The I/T ratio and CRP and TNF-α levels of blood at D0, white matter injury on MRI at discharge, head circumference and seizure spikes on aEEG at near-term age were associated with Bayley-III scores at a CA of 18 months.ConclusionsSystemic inflammation induced by clinical infection and NEC are associated with neurodevelopmental impairment in preterm infants. The seizure spike on aEEG, elevated I/T ratio, CRP, and plasma TNF-alpha during inflammatory episodes are associated with poor neurodevelopment.