Hot seat case #100 Denouement: 6 wk old F with ear drainage

Posted on: October 12, 2017, by :

Sam Zhao, MD Children’s National Medical Center

The Case:
6 wk old ex-33 weeker presented with unilateral purulent ear drainage x 2 weeks with increasing fussiness, but afebrile. Maternal history was relevant for SLE, HIV (undetectable viral load during pregnancy) and HSV (on acyclovir during pregnancy without active lesions during delivery). This resultantly complicated the NICU stay in that the patient was on HIV prophylaxis for one month until told to discontinue by Special Immunology.

Here’s How You Answered Our Questions:

 

Discussion:

This child made us uncomfortable as a group because let’s be honest, neonates are untrustworthy! The concern for this neonate was otitis externa that may be complicated with tympanic membrane rupture and/or middle ear extension. Is this mastoiditis in a neonate who is not showing the typical signs/symptoms one would expect or is this even more involved with intracranial extension causing a brain abscess. For some of us, the lack of fever was reassuring, but Dr. Zaveri reminded us that that neonates often have subtle findings that may point to more serious pathology. Dr. Zhao stated that special immunology had cleared this child from the HIV suspicion and stated should have an otherwise typical neonatal immune system.

Everyone agreed that this childs otorrhea needs to be cultured, however, the lumbar puncture was not so straight forward. None of the fellows felt the need to tap this child, whereas, some of the Attendings felt the pre-test probability was higher for a lumbar puncture than a urine culture. Temporal bone imaging was a must for this neonate to help in our decision making and disposition. Most felt the ultrasound would not add anything nor would it deter the need for a CT scan so most chose to forgo.

Dr. Chapman and Dr. Guse reminded us how sparse the literature is for local vs. systemic antibiotic use in the setting of ruptured AOM. As many things in medicine it becomes a stylistic thing. Some of the attendings use only local antibiotics, others use only systemic, and some use both. The definite roll for systemic antibiotics was deemed necessary for systemic features such as fever.

Denouement:

The patient was discussed with both ENT given her young age and ID given her complicated prenatal history. ENT wanted to use Ciprofloxacin/dexamethasone drops but were concerned about steroid use at an early age. This was approved by the ID team, who also recommended the addition of piperacillin/tazobactam for anti-pseudomonal coverage (ceftazidime was unavailable due to hospital shortage). Blood culture had no growth but ear culture grew Staphylococcus aureus (MSSA) that was resistant to clindamycin, erythromycin, and penicillin. Patient’s ear drainage improved and she was discharged home to complete a 10-day course of ciprofloxacin/dexamethasone drops and cefdinir PO.

Nuntigar Sonsuwan, Patcharin Watcharinyanon, Kittisak Sawanyawisuth. What are the leading causative pathogens in acute otitis media with tympanic membrane perforation? International Journal of Pediatric Otorhinolaryngology, Volume 90, 2016, Pages 20-22, ISSN 0165-5876.
(http://www.sciencedirect.com/science/article/pii/S0165587616302786)

Are topical antibiotics an alternative to oral antibiotics for children with acute otitis media and ear discharge?
http://www.bmj.com/content/352/bmj.i308.long

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.

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