1. 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

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

3. Chief complaint
Prematurity 29+4wks with fetal distress

4. 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
2016/10/ :23

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. CXR

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

13. Brain echo

14. Bedside abdominal echo

15. Placenta culture and blood culture, CSF culture

16. 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

17. Discussion
Listeriosis

19. 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

21. 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

23. 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

24. 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

25. 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

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

28. Neonatal listeriosis

29. 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

30. 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

31. for your attention