1. Intern.李家騏 Supervisor: Dr. 沈靜芬
2019/5/10
Clinical case presentation: one female newborn presented with fever and tachypnea after birth
Intern.李家騏
Supervisor: Dr. 沈靜芬

2. Identifying information
2019/5/10
Identifying information
Name: 方X涵
Chart number: 170xx746
Sex: female
Age: Newborn
Date of birth and admission: 7/19

3. On admission Fever after birth (rectal temperature: 38.3’ C)
2019/5/10
On admission
She was presented with
Fever after birth (rectal temperature: 38.3’ C)
Tachypnea, nasal flaring and subcostal retraction
SpO2:97%
Normal PO2 in newborn: mmHg
Na: K:
C:8.1-11 P:
Cl:

4. On admission Birth history:
2019/5/10
On admission
Birth history:
GA: 35+6 weeks, late preterm
G5P1AA4, Cesarean section due to maternal fever, DOIC(-), PPROM (-) (7/19 9:38 ROM; 9:39 birth)
Apar score: 6 ---> 9
Birth body weight:2195g (borderline SGA; 10th %); Body length: 44cm (10-25th %); Head circumstances: 33cm (75-90th %)
His prenatal care at our OPD was uneventful: level II sonography revealed no fetal anomaly; no maternal GDM or PIH/pre-eclampsia; Amniocentesis(-)

5. 2019/5/10
Maternal history (1)
She went to ER due to fever up to 38.9’ C with sorethroat and general soreness on 7/18.
24-year-old female with HIV on HAART
GBS(-)
Lab data:
Urine: WBC: 17
Influenza virus type A antigen : positive
Impression: HIV infection + UTI + Influenza A
 cytomegalovirus, herpes simplex virus, hepatitis B, hepatitis C, syphilis, toxoplasmosis, or tuberculosis.

6. 2019/5/10
Maternal history
Diagnosed with HIV infection since 2012, HAART at our OPD since late Janurary, 2015 (GA: 11weeks)
Therapy
Combivir+Azatanavir use until C/S
Zidovudine 1 vial before C/S
Rocephin for UTI
Refused Tamiflu
Lab data:
HIV viral load (viral nucleic acid detection): 157 on 2/16; not detected on 5/8 and 7/22;
CD4: on 7/15  moderate suppresion
Previous kaletra with severe diarrhea
Antenatal steroid wasn’t used
Lamivudine. +. Zidovudine

7. 2019/5/10
Maternal history
Lab data:
VDRL: non-reactive on 5/6

8. 2019/5/10
Family history
Mother: HIV infection

9. Physical examination Physical examination revealed:
2019/5/10
Physical examination
Physical examination revealed:
T: 38.3’C ; P:158/min ; R:68/min BP: 62/38mmHg
SpO2:97% (under nasal CPAP FiO2 26%)
Abdomen: Inspection: globular Palpation: soft, no organomegaly, Percussion: tympanic Auscultation: BS: normoactive
Limbs: warm, no edema, cyanosis (-), lateral weakness (-), palmar erythema (-)
Peripheral pulse: symmetric and active
Skin: no edema,petechiae or ecchymosis
Consciousness: clear
Sclera: not icteric
Neck: supple, LAP (-)
Chest: Inspection: symmetric expansion Palpation: no crepitus Percussion: resonance Auscultation: coarse BS
Heart: Palpation: no heave, no thrill Percussion: no increase of dullness Auscultation: RHB, no murmur

10. Lab data 2019/5/10 Preterm Hb:15.7+-2.32 McV108.7+-6.15 Wbc: 13.9+-5.7
Plt:
UTI typically presents in the second or third week after birth in term infants [1]. The incidence of UTI is low in the first few days of life (2 percent) even in neonates who are bacteremic [4]. As a result, urine cultures are not obtained for term infants who are being evaluated for early-onset sepsis before the first six days of life. 

11. Lab data Influenza A,B (-) Virus isolation(-) Blood culture(-)
2019/5/10
Lab data
Influenza A,B (-)
Virus isolation(-)
Blood culture(-)
CSF culture (-)
7/19 pH
7.255
PCO2
68.3
PaO2 54
HCO3
23.4
BE(ecf)
-3.7
BE(B)
-4.4
SaO2
89.5
7/19
Na+
133.5 K+
3.98
Ca2+
1.175
Cl-
106.3
Hct(%)
40.5
Preterm
Hb:
McV
Wbc:
Plt:
UTI typically presents in the second or third week after birth in term infants [1]. The incidence of UTI is low in the first few days of life (2 percent) even in neonates who are bacteremic [4]. As a result, urine cultures are not obtained for term infants who are being evaluated for early-onset sepsis before the first six days of life. 

12. Image 7/19 2019/5/10 Film of chest AP view shows:
1. OG tube inserted in place.
2. Coarsening of bilateral bronchivascular bundle with fine granulation of lung parenchyma, compatible with the clinical information of preterm related hyaline membrane disease.
3. Suspicious for pnemomediastinum, interval improving.
4. Both CP angles are sharp.

13. Impression and plan Prematurity 35+6 weeks, borderline SGA
2019/5/10
Impression and plan
Impression
Prematurity 35+6 weeks, borderline SGA
Neonatal fever
Respiratory distress
Maternal HIV infection
Respiratory distress, suspect TTNB or pneumonitis

14. Impression and plan Septic work up
2019/5/10
Impression and plan
Plan in NICU
Septic work up
Empiric antibiotic: ampicillin + gentamicin
Prophylactic anti-flu drug: Tamiflu
Ventilator support (Nasal CPAP)
Prophylactic antiretroviral drug : Zidovudine (six weeks)
Isolation from mother breast milk
必須cover GBS, E.coli, meningitis:s.pneumonia; H.influenza, Neisseria.meningitis, listeria
Ampicillin: GPC+listeria
Gentamicin: GNB, pseudomona
Amp+cefataxime也是選擇 因為E.coli 對gentamicin的抗藥性越來越強，而且cefataxime對BBB的穿透力強

15. NICU day 2 (7/20) Tachypnea and subcostal retraction
2019/5/10
NICU day 2 (7/20)
Respiratory distress syndrome, Gr. II
Tachypnea and subcostal retraction
T/P/R:36.7/145/62 BP90/42mmHg  fever subsided
Chest X ray: airbronchogram; R’t pneumomediastinum
Nasal CPAP ----
Bubble CPAP
NG feeding
7/20 pH
7.249
PCO2
62.3
PaO2
36.3
HCO3
26.6
BE(ecf)
-0.6
BE(B) -2
SaO2
58.1

16. NICU day 3 (7/21) 7/21 Tachypnea (up to 100/min)
2019/5/10
Respiratory distress syndrome, Gr. II
NICU day 3 (7/21)
7/21
Tachypnea (up to 100/min)
Mildly improved Chest X-ray
Improved gas data
Start trophic feeding, SSC20
Keep Bubble CPAP
7/21 pH
7.352
PCO2
48.8
PaO2
51.8
HCO3
26.4
BE(ecf)
0.9
BE(B)
0.2
SO2
84.4

17. NICU day 4-8 (7/22-7/27) Improved gas data on 7/22
2019/5/10
NICU day 4-8 (7/22-7/27)
Improved gas data on 7/22
Try room air on 7/26
Transfer to level II on 7/27
7/22 pH
7.353
PCO2
48.4
PaO2
60.9
HCO3
26.3
BE(ecf)
0.6
BE(B)
0.1
SaO2 89

18. Level II No tachypnea or subcostal retraction was noted
2019/5/10
Level II
No tachypnea or subcostal retraction was noted
NG feeding with SSC 20 or Donated milk as tolerance
PCR I of HIV : (-)
Under zidovudine (week 2)

19. Case discussion How to prevent perinatal HIV transmission?
2019/5/10
Case discussion
How to prevent perinatal HIV transmission?
How to diagnose HIV infection in newborn?
Vaccination in suspected HIV-infected newborn.

20. How to prevent perinatal HIV transmission?
Without ARV drugs during pregnancy, risk of transmission from mother to infant is 1 in 4
Pediatric AIDS Clinical Trials Group (PACTG) 076 found that by giving zidovudine (ZDV) to the pregnant woman during pregnancy, labor, and delivery, and to her newborn, transmission could be reduced to 8%
The risk of perinatal transmission can now be less than 2% (1 in 50) with:
Highly effective ARV therapy (HAART)
Elective Cesarean section as appropriate
Formula feeding
 efavirenz should be avoided during the first eight weeks of pregnancy because of concern for a potential risk of neural tube defects. In contrast, treatment-experienced women with a suppressed viral load on an efavirenz-containing regimen who become pregnant should continue efavirenz. 
預防母子垂直傳染的愛滋病最有效的方法，是母親懷孕第二期起服用抗<I2>病毒藥物，生產過程中施打zidovudine(ZDV)、或口服ZDV+lamivudine、或nevirapine，<I2>及嬰兒產出後不餵食母乳、並給予ZDV口服液。完善的照護可讓嬰兒得到HIV感染的機會降到百分之二以下。

21. How to prevent perinatal HIV transmission?
In general, the risk of perinatal transmission declines with low levels of maternal HIV RNA level
Women with a non-detectable viral load can still transmit HIV to their infants
若媽媽感染HIV，在整個懷孕到分娩的過程中沒有服用抗愛滋病毒藥物，則生下的嬰兒有15-30%的機率感染HIV，其中三分之一(5-10%)是在懷孕期得到的，三分之二(10-20%)則是經由產痛以及分娩過程感染；若產後又餵哺母乳至嬰兒六個月大時，則感染率會增加至25-35%；若持續餵哺母乳至兩歲，則有高達30-45%的嬰兒會感染HIV
all HIV-infected pregnant women should take antiretroviral prophylaxis to prevent mother-to-child transmission of HIV, regardless of their CD4 cell counts or HIV RNA levels

22. How to prevent perinatal HIV transmission?
During pregnancy
If HIV-infected mothers took antiretroviral prophylaxis only for prevention of mother-to-child transmission
Start the treatment at GA 12 week, no later than 14 weeks
First choice for prevention of mother-to-child transmission was Combivir (Lamivudine, Zidovudine)
Good placental permeability
NRTI（nucleoside reverse-transcriptase inhibitors；
Combivir (Lamivudine, Zidovudine

23. How to prevent perinatal HIV transmission?
During labor
Infants of women who have received antepartum ARV drugs but have detectable viremia (HIV RNA >1000 copies/mL) -> scheduled cesarean. 
Initially Zidovudine（2 mg/kg* BW）intravenous drip for one hour, and then 1 mg/kg*BW per hour as maintain dose
ZDV crosses the placenta rapidly and can provide pre-exposure prophylaxis to the fetus.

24. Infant antiretroviral prophylaxis
How to prevent perinatal HIV transmission?
Infant antiretroviral prophylaxis
Maternal antepartum ARV drugs
Zidovudine (ZDV) for 6 weeks, and ideally initiated within hours of delivery.
No maternal antepartum ARV drugs
 Zidovudine prophylaxis combined with 3 doses of nevirapine in the first week of life (at birth, 48 hours later, and 96 hours after the second dose).

25. 2. How to diagnose HIV infection in newborn?
Serial qualitative DNA PCR is currently the accepted standard for early diagnosis
DNA-PCR [2 consecutive readings]
1-2 months
3-6 months
Antibodies (Elisa)
12 months in non-breastfed infant
Others – RNA PCR, p24, viral culture
Passive transfer of maternal Ig G leads to detectable antibody in uninfected children for up to 18 months
Antibody tests e.g.ELISA not diagnostic until 18 months unless negative

26. 3. Vaccination in suspected HIV-infected newborn.
疑似愛滋寶寶的疫苗接種
尚未確診感染HIV之前，其接種時程與疫苗種類與一般嬰兒無異。
確定感染HIV的嬰兒，只要沒有症狀、免疫力未低下，皆應該接種所有的不活化疫苗、麻疹、德國麻疹、腮腺炎疫苗、水痘疫苗及卡介苗。

27. 2019/5/10
Reference

28. Thank you for your attention!
2019/5/10
Thank you for your attention!