Hot Seat: You’re as Cold as IcePosted on: April 4, 2022, by : Brian Lee
Case by: Masouma Mohamed, PGY4, Inova PEM fellowship
HPI: 50 day old, ex FT, born to GBS negative mom, presents to the ER with low temperature. The child was doing well until 4 hours prior to presentation, when mom noticed that she felt cool to touch with forehead sweating. Mother checked a rectal temperature, and it was 94 F, so is bringing the child to the ED. Mother states that the child had been doing well this morning but now seems sleepier. There have been no URI sx, no diarrhea. She does note increased spit-ups. Mother also mentioned intermittent, brief jerking episodes that she has noticed over the last week.
Gen: increased fatigue, low temperature
HEENT: No URI sx
CV: no sweating with feeds
Pulm: No cough, no difficulty breathing
GI: Increased spit ups, but no blood or bile, no diarrhea
GU: Nml number of wet diapers
Neuro: Sporadic episodes of extremity shakes/jerks (last for 1-2 seconds and then stop). No fatigue afterwards. No truncal shaking or jerking movements.
PMHx: FT, SVD. No Nicu stay. Mother had no prenatal complications, GBS negative, no history of HSV
Vitals: Temp 93.7 F ( 34.5 C), HR 107, BP: 116/70, RR: 38, SPO2 97% on RA; Wt 4.7 Kg
Gen: Fussy, but will console intermittently with mother
HEENT: AFOSF, PERRLA, conjunctiva are normal
Pulm: Normal breath sounds, CTAB
CV: Normal cap refill, no murmurs, gallops.
GI: Soft, distended, normal bowel sounds.
Neuro: mildly decreased tone but is spontaneously moving all extremities, normal reflexes.
Skin: No rashes, no skin signs of trauma.
Initial Workup on Arrival:
POC Glucose: 221
Istat: 7.38/38.2/23/-2 Lactate: 1.5
CBC: 6.42<10.4/30.8>478 ANC 3000
AST 37, ALT 29, ALK PO4 335, Bili 1.7
Urine: Negative LE, nitrites, no WBC
Blood culture and urine culture were sent.
Respiratory pathogen panel was sent.
Pt temperature is improving under the warmer, rectal temp is 98 F. Pt sleepy, but appropriate when stimulated.
Despite being under the warmer, the child continues to be sleepy, so decision is made to proceed with lumbar puncture:
CSF analysis: WBC 140, RBC 164,000, Glucose 84, Protein 816. Gram Stain negative for organisms
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