The patient is a 28 day old ex-FT female presenting with abnormal movement.

When the patient was waking up from sleep this AM, parents noted a period of bilateral upper extremity stiffening and foaming at the mouth with associated R sided head deviation and eyes rolling back. The episode lasted < 1 min. Patient was minimally responsive during the episode without cyanosis. She immediately went back to her baseline afterward. Family notes that patient is a fussy baby at baseline with periods of colicky crying and is at her baseline right now.

No fevers, vomiting, diarrhea, rash. They have noted some mild congestion over the past week. No sick contacts. She is tolerating PO as per her baseline with good reported weight gain at PCP. No recent falls or head trauma noted.

Prenatal Hx:

Pregnancy complicated by preterm labor requiring bed rest. During delivery, patient with NRFHT and required emergent C-section. Patient did have a tight nuchal cord. Did not require any further monitoring or NICU stay.

ROS:
Constitutional: No fevers, weight loss.
Skin: denies rash
HEENT: Nasal congestion
Respiratory: denies cough, stridor, cyanosis, no increased WOB
Cardiovascular: denies nursing cyanosis, denies nursing diaphoresis
Gastrointestinal: no vomiting, no diarrhea
Genitourinary: no hematuria
Neurologic: + concern for seizure
Hematologic: no bruising, no petechiae

Family history: Mother has history of migraines associated with convulsions (per report), otherwise no family history of epilepsy.

Exam
VS: Temp 36.9C HR 144 BP 78/62 RR 28 100% on RA
General: Non-toxic appearing, alert, intermittently fussy but consolable during exam, smiling and playful
Skin: Warm, intact, no rashes, no notable external bruising or skin changes on full head-toe exam
Head: Normocephalic, atraumatic, anterior fontanelle soft and flat
Eyes: PERRL, extraocular movements intact, tracking mothers face intermittently, normal conjunctiva
ENT: Oral mucosa moist, no oral lesions
Cardiovascular: regular rate and rhythm, no murmur, normal peripheral perfusion
Respiratory: Lungs clear to auscultation, respirations non-labored, non-tachypneic
Gastrointestinal: Soft, non-tender, non-distended, no organomegaly
Neurological: Moves all extremities equally, symmetric tone bulk and strength and upper and lower extremities

You watch the video that parents took (only < 5 seconds long captured) where end of the episode was captured with bilateral upper extremity stiffening, eye rolling.

Given the patient’s well-appearance without fever, you talk to neurology first. They recommend CBC, CMP, UA, UDS, EKG, and a Head US. They recommend disposition to the NICU given neonate with seizure presentation.

NICU is called for disposition, who additionally recommend blood culture, lumbar puncture (for usual studies and HSV PCR), lactate, ammonia. They recommend starting ampicillin and ceftazidime while awaiting laboratory results.

Preliminary results:
WBC: 10.06, H/H: 14.7/41, Pts 296, ANC 1.38
CMP: Na 137, K 5.5, CO2 21, BUN 9, Cr 0.18, Glucose 98, LFTs (AST 39, ALT 31,ALK 590)
UDS: Negative
UA: 2 WBC, Negative LE, Neg Nitrites

Head US:
Subtle echogenic focus near the left parietal occipital sulcus, may be related to technique. Small hemorrhage/infarct  is not entirely excluded. No large parenchymal hemorrhages or intraventricular hemorrhage. Small lateral ventricles and extra-axial spaces.

Patient is transferred to the NICU in 20 minutes (given bed availability) and lumbar puncture is performed there.

Stayed tuned for this case’s denouement.