An Unlikely Cause of Neonatal Sepsis

A 4-day-old previously healthy female neonate presented to the emergency department with lethargy, irritability, decreased urine output, and poor feeding of 6-hour duration. She was born at 37 weeks’ gestation via induced vaginal delivery secondary to preeclampsia to a 24-year-old gravida 2 para 1 mother. Screening had been negative for maternal group B streptococcal colonization, HIV, syphilis, Neisseria gonorrhoeae, and Chlamydia. Labor was 14 hours with rupture of membranes 6 hours prior to delivery. The mother was afebrile during labor and the delivery was uneventful. Birth weight was 3.05 kg. The mother and her child were discharged home after a 48-hour hospital stay. The neonate appeared healthy and fed well until the fourth day of life when she became ill. Examination on admission to the emergency department revealed a temperature of 38.1°C (rectal), heart rate of 156 beats/min, blood pressure 64/45 mm Hg, respiratory rate 64 breaths/min, and pulse oximetry of 98% saturation on room air. Weight was 3 kg (15th percentile) and length was 46 cm (10th percentile). She was lethargic and poorly responsive. Her anterior fontanelle was soft and flat and her neck was supple. She demonstrated no increased work of breathing and exhibited normal auscultation bilaterally in all lung fields. Heart examination revealed a regular rate and rhythm with a II/VI systolic heart murmur best heard at the left upper sternal border, second intercostal space. The abdomen was soft, nontender, and nondistended with no masses. The patient had no rashes or skin lesions and no sacral dimple or any other lumbosacral abnormalities. She had good tone, flexed posture, and symmetric Moro reflex but was irritable when examined. In the emergency department, she underwent a full sepsis workup as our patient presented with a core temperature higher than 38°C suggestive of sepsis in a term neonate. The initial complete blood count was significant for leukopenia at 1500 white blood cells/μL (normal 5000-21 000/μL), 36% neutrophils, 4% bands, and 52% lymphocytes. Urinalysis showed many bacteria but negative leukocyte esterase and nitrites. Total bilirubin was 18.7 mg/dL (normal <12 mg/dL) with direct bilirubin of 0.5 mg/dL (normal <0.6 mg/dL). Complete metabolic panel revealed glucose 103 mg/dL (normal 50-90 mg/dL), blood urea nitrogen 7 mg/dL (normal 2-19 mg/dL), creatinine 0.5 mg/dL (normal 0.3-1 mg/dL), Na 137 mEq/L (normal 130-145 mEq/L), K 5.9 mEq/L (normal 3.7-5.9 mEq/L), Cl 104 mEq/L (normal 97-108 mEq/L), CO 2 17 mm Hg (normal 32-48 mm Hg), and Ca 9.3 mg/dL (normal 7.6-10.4 mg/dL). An anion gap of 16 and CO 2 17 mm Hg indicated a metabolic acidosis. Chest and abdominal radiographs were unremarkable. Phototherapy was started for hyperbilirubinemia presumably secondary to sepsis. Blood and urine cultures were obtained and a lumbar puncture was performed but insufficient cerebrospinal fluid (CSF) was obtained for a cell count and chemistries. The CSF Gram stain showed Gram positive cocci in pairs and chains. Intravenous ampicillin, cefotaxime, and gentamicin were started and the baby was transferred to the pediatric intensive care unit. Urine culture was negative. Both blood and CSF cultures were positive for group D Streptococcus, S gallolyticus subsp. gallolyticus, sensitive to penicillin, daptomycin, linezolid, and vancomycin. Identification was made by RapID STR and 16S rDNA gene sequencing. Antibiotic coverage was deescalated to intravenous ampicillin monotherapy at 300 mg/kg/d divided into 4 doses a day. 591894 CPJXXX10.1177/0009922815591894Clinical PediatricsKennedy et al research-article2015