Hot Seat #177: To LP or Not to LP?

Posted on: September 27, 2021, by :

Nichole McCollum, MD, Children’s National Medical Center

Patient #1 (AD): 13-week-old ex-26 week infant presents with cough, NBNB post tussive emesis and bradycardia on apnea monitor in the setting of known RSV infection. No fever. No cyanosis. Tolerating PO and normal UOP. Upon arrival to ED, patient is noted to have an apneic episode lasting approximately 30 seconds resolved with stimulation by bedside RN. Unable to get in touch with MD who prescribed the apnea monitor for download/review.

Vital signs: Rectal temp: 36.8C, HR 144, RR 50, BP 95/73, SpO2 100% on RA

Exam-alert, smiling, RRR, cap RF <2 sec, femoral pulse 2+ bilaterally, mild subcostal retractions, diffuse coarse crackles, abdomen soft, non-tender, non-distended.

Patient #2 (LB): 15 m/o M with no significant past medical history presents as a transfer from an OSH for further evaluation and treatment.  He had a 20 minute GTC seizure, returned to baseline within 1 hour.  Went to OSH who obtained CBC, blood culture, CMP and UA- all normal.  Given ceftriaxone due to complex febrile seizure prior to transfer.  

Vitals Signs: Temp: 37.2C, HR 121, RR 32, BP 90/51, Sat 100% on RA

Exam- Alert, appropriate interaction for age, smiling, EOMI, PERRL, MMM, RRR, brisk cap refill, easy WOB, lungs clear, abdomen soft, non-tender, symmetric smile and facial movements, tongue midline, palate lifts symmetrically, sits and stands without support, strength 5/5, patella DTR 2+ bilaterally, erythematous papules and vesicles around mouth, wrists, palms, diaper area, feet.

You discuss AD with NICU to admit for observation who recommends a full sepsis work up including LP and starting antibiotics. You discuss LB with neurology to admit for observation who recommends CSF studies without additional antibiotics or antivirals. 

You discuss the recommended plans with both parents.  AD’s parents refuse the LP and urine studies but they agree to labs and admission for observation. LB’s parents agree to the CSF studies and admission for observation. You obtain labs on AD and CSF studies on LB. 

AD was ultimately admitted with basic lab work without LP, without urine studies, and without starting antibiotics.

LB received a lumbar puncture: CSF with WBC 0 and normal protein and glucose, and meningitis/encephalitis PCR panel negative. He was admitted to neurology service for EEG.

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.

Walter Palmer
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1 thought on “Hot Seat #177: To LP or Not to LP?

  1. Immunization status for patient LB would also influence my decision on whether to not to perform lumbar puncture.

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