Hot Seat Case Denouement #125: 16 day old with lethargy

Posted on: February 14, 2019, by :

Mary Beth Howard, MD Children’s National Medical Center

Case: 16 day old FT male with 2 days of fussiness and poor feeding. Parents felt the infant was sleepier than usual and often had to be awakened to feed. Mother was GBS positive and inadequately treated. On exam was afebrile with normal vital signs but pale, sleeping (2am) but arousable to vigorous stimulation and poor suck.

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Discussion:

Ah, yet another neonate doing neonate-y things! Sleepy, vomiting, afebrile, but just not acting right. This is a typical case that gets ingrained in our head as sepsis, sepsis, sepsis! Finally, 100th on the list is a potential inborn error of metabolism, which Dr. Agrawal harped on in the commentary. Interestingly, the vast majority of attendings would do a complete sepsis evaluation from the beginning, while only two fellows who voted seemed to want CSF studies early on. In my mind, and many experienced providers agreed, an ill appearing neonate needs to be broadly covered for sepsis even without fever and that includes acyclovir for HSV.

Drs. Patel and Cahill reminded us that intussception could still be on the differential, despite it being unusual and rare in this age group. Hence their reasoning for the abdominal ultrasound in the emergency department.

Dr. Weiner also mentioned NAT as something to keep in the back of our mind in a vomiting, afebrile neonate because crying babies are unfortunately high risk. Often times, we as ED providers have to pull that trigger and it is a hard trigger to pull on someone you just met. But as many experienced providers reminded us, we may have time especially if we feel the child needs a medical admission and to pass that suspicion on to the inpatient team to get their impression as well as a fresh set of eyes! But of course, this case takes a turn for the better (thankfully!) with the diagnosis.

Denouement:

The patient was admitted to the Hospitalist service and continued to be lethargic (responsive to stimulation only) while on IV antibiotics. He was noted to have persistent NBNB emesis after feeds so an abdominal US was performed and he was found to have pyloric stenosis. He underwent a pyloromyotomy with subsequent improvement in feeding tolerance, return to euvolemia and normal neurologic exam.


The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Haroon Shaukat MD

Pediatric Emergency Medicine Attending at Children's National Health System
I was born and raised in Silver Spring, Maryland, but with very little knowledge of all things DC. “Crabs and football, that’s what Maryland does”, unfortunately I could only partake in one of those. I grew up with a crab allergy so blue crabs are a make believe creature to me, much like the lochness monster. I decided to take the leap of faith and attend medical school abroad but family and home could not keep me away for too long. Residency took me to New Jersey where I began to cultivate my love for medical education and low tolerance for poor pain control. Did I mention I also learned that I outgrew my crab allergy in NJ! Alas, to the DMV I return! Hopefully to contribute to medical education and quality improvement while feasting on a Maryland blue crab or two.
Haroon Shaukat MD

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