Hot Seat: You’re as Cold as Ice
Posted 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.
ROS:
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
Exam:
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
CMP: 135/4.9,103/21,10/0.5<236
AST 37, ALT 29, ALK PO4 335, Bili 1.7
Ammonia 46
Urine: Negative LE, nitrites, no WBC
PCT: 0.15
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
The information in these cases has been changed to protect patient identity and confidentiality. The images are are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
This is a great case that gets at one of the key roles of the PEM provider: identifying a sick child vs. a non-sick child. This is a sick child.
While her vital signs don’t show a child in shock, this is a hypothermic infant with neurologic symptoms who has meningitis/sepsis until proven otherwise. She needs urgent LP and initiation of broad spectrum antibiotics. The lack of maternal history of HSV should not reassure the PEM physician, as most cases of infantile HSV are with primary infection of the mother.
The question about imaging is also a good one, and I look forward to discussion on that point. Neurologic signs/seizures in infants are always hard to pick up, as their brain is not fully myelinated, their clinical signs can be tricky. We think of focal seizures as being cause for alarm for a CNS lesion that may show up on imaging, however, in an infant who has episodes of ‘shaking’, it is hard to know how high our suspicion should be. These episodes could be benign normal newborn movements (like an exaggerated moro response) or they could be seizures. Given that this child is ill, I would err on the side of obtaining some imaging of her brain in the ED.