2016/11/11 Presenter: R2徐子權 Supervisor CR 呂筱涵 VS林永傑 Case Discussion 2016/11/11 Presenter: R2徐子權 Supervisor CR 呂筱涵 VS林永傑

Patient profile Name: 王OO之女 A 0-day-old baby girl Chart number: 1789XXXX Admission date: 2016/10/29 17890354

Chief complaint Prematurity 29+4wks with fetal distress

Present illness A 38 year-old mother, Hyperthyroidism about 10 years, with thyroid storm*3, under PTU 50 mg 1# QD Uterine myoma, several, max 7*6 cm GDM under diet control. No PIH, pre-eclampsia, or eclampsia. Prenatal: NIPS: WNL, level II sonography: WNL, Amniocentesis was not done. Maternal fever 38.1°C with chillness, visited ER, pyuria Blood culture, oral cephalexin Blood culture showed positive result ->admitted FHB: 212bpm. Poor variability. Late deceleration TAUS: suspected fetal ascites 2016/10/27 23:26 Mother’s ID 17795496 2016/10/29 00:23

Neopuff bagging, CPCR for 10 minutes, 2016/10/29 20:00 born C/S, MSAF: moderate Neopuff bagging, CPCR for 10 minutes, Intubation(nasal endo), mucin-like meconium was suctioned from the airway, GA:29+3wks, BBW:1492gm, G3P1SA2, DOIC(+), APGAR score:1->2->3->6 =>NICU

Past history Growth: BW: 1494g (50-75th percentile), BL: 40cm (50-75th percentile) HC:28 cm (50-75th percentile) Feeding: NPO Developmental milestones: Newborn Drug Allergy History: NKFDA Vaccination: not yet Family tree: TOCC: Mother denied taking raw food. Drink 市售milk. Father and grandfather work at hog house(豬舍) SA1: GA 11 W, +FHB initially SA2: blighted ovum

Physical examination Vital Sign: T:36.8°C, P: 169/min, R: 51/min; BP: 61/41mmHg Anterior fontanel: 2 f.b.; Fracture: no; Cephalohematoma:no; Caput succedaneum: no Chest: Breath pattern: smooth under ventilator support Breathing sound: bilateral rales Heart sound: regular heart beat, no murmur Abdomen: soft, ovoid, normoactive bowel sound Extremities: no skin rash, no pitting edema Neuro: Moro`s reflex: weak; Grasp reflex: yes; Sucking/Rooting reflex: normal Barbinski SIGN: dorsi/dorsi flexion; Tonicity: no hypotonia

Tentative impression 1.Prematurity GA29+3 weeks 2.Maternal listeria monocytogenes bacteremia with fetal distress 3.Meconium aspiration syndrome with airway obstruction post CPCR 10mins

Diagnostic plan and Management Check CBC/DC, CRP, micro-gas, CK, CK-MB, TnT Take CXR Take blood culture Brain echo lumbar puncture for CSF study High dose Ampicillin (300mg/kg/d) for maternal Listeria Monocytogene bacteremia, and Gentamycin 5mg/kg/dose QOD Ventilator support

High dose Ampicillin (300mg/kg/d) for maternal Listeria Monocytogene bacteremia, and Gentamycin 5mg/kg/dose QOD Ventilator support

CXR

Lab data 備註: 1 Corrected WBC: 1333 /μL.(因NRBC干擾WBC測試)

Brain echo

Bedside abdominal echo

Placenta culture and blood culture, CSF culture

Final diagnosis Maternal listeria monocytogenes bacteremia with fetal distress Meconium aspiration syndrome with airway obstruction post CPCR 10mins Chorioamnionitis with listeria monocytogenes bacteremia and sepsis, suspect prenatal shock Intraventricular hemorrhage Gr.III, bilateral

Discussion Listeriosis

Listeria, facultatively anaerobic, Gram-positive bacilli, non–spore forming, motile, catalase positive   Listeriosis is predominantly a foodborne illness, with sporadic and outbreak-related cases tied to consumption of food contaminated with listeria (Listeria monocytogenes) The incidence of listeriosis associated with pregnancy is approximately 13 times higher than in the general population Maternal infection, usual presentation in the 2nd and 3rd trimesters may present as a nonspecific, flu-like illness with fever, myalgia, backache, and headache, often preceded by diarrhea or other gastrointestinal symptoms

Fetal and neonatal infections can be severe, leading to fetal loss, preterm labor, neonatal sepsis, meningitis, and death A case series of 11 pregnant women with listeriosis and an accompanying review of 222 cases found that one in five pregnancies complicated by listeriosis resulted in spontaneous abortion or stillbirth two thirds of surviving infants developed clinical neonatal listeriosis

Diagnosis  An exposed pregnant woman with a fever higher than 38.1°C (100.6°F) and signs and symptoms consistent with listeriosis should be simultaneously tested and treated for presumptive listeriosis Diagnosis is made primarily by blood culture Placental cultures If blood cultures are negative after the recommended antibiotic regimen has begun, the decision about whether or not to continue antibiotics should be made using clinical judgment

Treatment (mother) High-dose intravenous ampicillin (at least 6 g/day) for non-allergic patients for at least 14 days. Gentamicin is added to the treatment regimen because it has demonstrated synergism with ampicillin Women who are allergic to penicillin, ampicillin; trimethoprim with sulfamethoxazole is the generally recommended alternative to ampicillin

Neonatal Listeriosis: Early-onset neonatal disease (<5 days, usually within 1-2 days of birth), a predominantly septicemic form late-onset neonatal disease (>5 days, mean 14 days of life), a predominantly meningitic form Listeriosis is indistinguishable clinically from neonatal sepsis and meningitis due to other organisms. The presence of increased peripheral blood monocytes suggests the possibility of listeriosis

5.2-20.6

Neonatal Listeriosis Pediatrics in Review Vol.25 No.5 May 2004

Neonatal listeriosis

Prognosis The mortality rate is >50% for premature infants infected in utero, 30% for early-onset neonatal sepsis, 15% for late-onset neonatal meningitis, <10% in older children with prompt institution of appropriate antimicrobial therapy Mental retardation, hydrocephalus, and other CNS sequelae are reported in survivors of Listeria meningitis

2015/08/06 prematurity GA:28wks boy 17079xxx CRP:147 after birth CSF: pleocytosis Listeria sepsis and meningitis with hydrocephalus 2015/9/04 Ommaya insertion 2015/11/06 VP shunt progressive enlargement of temporal and occipital horn on the f/u echo 105/1 s/p endoscopic fenestration on 105/3/4 much improvement of appetite after surgery 2016/4 CA: 6M:rolling ok 2016/7 CA 9 months, good interaction, crawl ok, sit steady 2016/10 CA 12 months walk with support, papa mama not yet 17079888

for your attention