Hot seat case #100: 6 wk old F with ear drainage
Posted on: October 4, 2017, by : Sam Zhao
Sam Zhao, MD Children’s National Medical Center
with Shilpa Patel, MD Children’s National Medical Center
The Case
6-week-old ex-33-week girl presents with ear drainage x 2 weeks. Mom states that the drainage has gotten progressively worse and more foul-smelling. The ear drainage started one week prior to NICU discharge. She was assessed at an OSH ED two days ago, where she was afebrile and discharged home without laboratory workup or imaging studies. Since then, she has become more fussy than usual and started spitting up her formula, which is not typical for her. She has not had fevers, but she seemed so uncomfortable that her parents decided to bring her back to the ED for re-evaluation.
ROS: + ear drainage, + fussiness, otherwise unremarkable
BH: born at 33 weeks via repeat C-section for pre-term labor weighing 1.6kg, GBS unknown, betamethasone given. Stayed in NICU x 4 weeks for feeding and growing. On HIV prophylaxis for one month until discontinued by Special Immunology. Received HepB vaccine.
FH: mom has SLE, HIV (undetectable viral load during pregnancy), HSV (on acyclovir during pregnancy with no active lesions during delivery)
SH: lives with parents and siblings
Meds: iron supplementation
PE: T 37.1, HR 130, BP 87/43, RR 44, O2 sat 100%
General: Patient is fussy but consolable.
HEENT: R external ear is erythematous and edematous with crusted drainage from the ear canal. Tissue in the ear canal is very friable and bleeds easily with manipulation. Subsequently with copious purulent drainage that obscures visualization of the TM. L external ear is normal with cerumen that obscures visualization of the TM. No significant erythema, swelling, or tenderness around the ears bilaterally.
Remainder of the exam is normal
A CBC is sent and shows WBC 5 with 24% N, 59% L, 14% M, 2% E, 0% B, no bands.
A head CT with contrast is performed and shows near total opacification of the R tympanic cavity and mastoid air cells. No intracranial extension or abscess is identified.
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Case 100! Sounds like acute otitis externa. The questions in my mind would be:
1. Is this malignant otitis externa/do I need to worry about pseudomonas (this is usually older immunocompromised folks though)?
2. Clarify that there are no vesicles to make us think Ramsay-Hunt/any Varicella exposure?
3. Is the maternal HIV and HSV hx relevant/should this tip me to be more aggressive with workup even though taken off HIV ppx?
4. If I do settle on plain old acute otitis externa, guidelines for treatment mainly apply to > 2 year olds, so how will I adapt for this host?
Would be inclined to admit to Hospitalist service with Pseudomonas coverage (Ceftazidime) until culture of that fluid is back. No abscess on CT so I am not sure ENT adds much.