1. A routine case of neonatal sepsis?
Andrew J Seier, MS4

2. HPI
3 weeks of age
ex-39 week uncomplicated (GBS negative) pregnancy and C-section (repeat) delivery
Routine prenatal labs were normal. 
Asymptomatic from birth until 1 day prior to presentation. Then,
uncharacteristic fussiness
decreased PO intake
rash across the mid-face (macular)
Home rectal temp of 102.1°F
Denies seizure-like activity, cough, vomiting, or diarrhea.
Patient's 3 year old brother recently had symptoms consistent with an upper respiratory infection
Both parents recovered from a suspected URI in the past month. They describe cough and sore throat
Received hepatitis B vaccine at delivery.
Since presentation she has been intermittently febrile, with Tmax 38.5°C

3. Physical exam
Vitals: T 37.2°C, HR 157 BPM, RR 38, BP 91/43, O2 sat 97% on room air
Positives
Grade II/VI systolic murmur
Subtle mottling visible to cephalad and caudad extremes.
Negatives
HEENT: [Normocephalic, atraumatic. Nares clear, moist pink mucosa without discharge. No pharyngeal erythema or exudates.]
Neck: [Soft, supple, no lymphadenopathy, full range of motion.]
Respiratory: [Lungs clear to auscultation bilaterally, no rales, rhonchi, or wheezes. Good air entry bilaterally, with no increased respiratory effort or accessory muscle use.]
Cardiovascular: [Regular in rate and rhythm, S1/S2 heard along right and left sternal borders. PMI non-displaced.]
Gastrointestinal: [Normal bowel sounds. Abdomen soft, non-tender, non-distended. No hepatosplenomegaly.]
Lymphatic: [No palpable lymphadenopathy in axillary, popliteal, or supraclavicular chains.]
Musculoskeletal: [Musculature normal in bulk and tone. No joint swelling, warmth, or tenderness to palpation. Full range of motion of upper and lower extremities.]
Skin: [No desquamation.]
Neurologic: [No weakness of upper or lower extremities. Sensation intact throughout. Pupils equal, round, and reactive to light. Extraocular movements intact.]

4. Assessment
This is a 3-week old female infant born of an uncomplicated pregnancy and delivery, presenting with fever (to 102.1°F), decreased PO intake and fussiness, with skin mottling and a previously unevaluated murmur. The parents and a sibling constitute sick contacts. She has been intermittently febrile to Tmax 101.3°F since admission. A full sepsis workup was done in the ED.

5. Sepsis workup CBC BMP 137/6.0/103/24/5/0.34, Ca 10.0
WBC 10.4, H&H 13.6/39.7, Plts 484
BMP 137/6.0/103/24/5/0.34, Ca 10.0
Blood culture obtained
CSF culture/chemistry/cytometry
Bloody; 5,610 RBCs; 2 nucleated cells/mm3; 63% PMN segs, 14% bands; glucose 55, protein 49
Urine culture obtained, negative
Respiratory screen, negative
Enterovirus, HSV-1/2, flu A/B, RSV, negative
VBG: 7.31/44/40/21
Started on ampicillin, gentamicin, and acyclovir

6. CSF Gram stain (example)

7. Differential?

8. Culture results
CSF and blood cultures turned positive at 17 and 41 hours, respectively
Culture report:
Streptococcus pyogenes , group A isolated
A very rare cause of neonatal sepsis and meningitis

9. Clinical course Fevers resolved
Overnight, some apneic episodes up to 1 minute in length: sats dropped to 70s
Rapid eye blinking noted after one episode
EEG ordered, showed 17 seizures in 1 night
Mostly EEG seizures, some clinically apparent
Neurology consulted:
MRI ordered
Started on phenobarbital and Dilantin

10. MRI results
Leptomeningeal enhancement consistent with known meningitis.
Moderate-sized area of restricted diffusion and enhancement in the left posterior temporal lobe most consistent with cerebritis.
Additional small of restricted diffusion with minimal, if any, enhancement in the right occipital lobe which could represent additional focus of cerebritis.
Possible small focus of restricted diffusion in the left frontal lobe without enhancement.
No evidence of brain abscess or empyema. No evidence of hemorrhage.

11. Historical perspective
Wilson, C. B. (2016). Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant (8th ed.). Elsevier.

12. Age<1 month: RR 3.7 mortality

13. Early-onset disease:
24 mothers, 18 culture-proven cases of vertical transmission
Late-onset disease
Method of transmission unknown
Small inoculum
Focal source

14. Summary
Group-A strep is a very rare cause of neonatal sepsis and meningitis, which was more common in the pre-antibiotic era
Unknown method of transmission in late-onset disease
High likelihood that most cases are due to vertical transmission
High mortality: 17-50%