Morning Report

Leah Farley, PGY-2 10/25/2013

Case
7 day old female transferred from an OSH for respiratory distress Birth History
Uncomplicated pregnancy with normal prenatal ultrasound Born at 38 weeks via NSVD Mom was GBS positive, other prenatal labs reassuring Infant observed for 48 hours in nursery and then discharged home with parents

About 12 hours of being home she had an episode of apnea associated with emesis that resolved with stimulation An hour later parents went to feed her but she seemed limp and she had another period of apnea She was stimulated and started breathing, however shortly afterward had another episode of apnea 911 called and she was admitted to OSH

Hospital Course
Developed oxygen need on hospital day 2 Blood cultures drawn and started on amp/gent Worsening hypoxia, respiratory distress and continued apneic episodes so she was started on HFNC LifeFlight was called for transport
Noted significant respiratory distress requiring intubation Hypotensive requiring fluid bolus and Dopamine

History
FH:
Paternal relatives with history of heart murmur. Dad and older half-brother with OSA 2/2 hypertrophied tonsils and adenoids. Mom and older half-sister healthy Dad with schizophrenia

SH: Lives in UT with both parents. 2 dogs at home. Mom and Dad smoke outside.

Physical Exam
Temp 35.5-36.2, P 150s-130s RR 32 on vent, BP 60s/30s, sats 92% on 70% FiO2, Weight 2.7 kg (2%ile) GENERAL: Sedated, intubated, non-irritable. EYES: PERRL, conjunctivae clear, sclerae nonicteric, HENT/MOUTH: NC/AT, AFSF, orally intubated MMM, LYMPH: Neck supple, no LAD. LUNGS: coarse bilaterally, no increased WOB, good aeration, no adventitious sounds, not breathing over the vent. CV: RRR, no M/R/G, nl perfusion and pulses. ABD: Soft, ND, liver edge palpable, nl BS, no masses GU: Nl external genitalia, nl Tanner stage for age, Foley catheter in place. BACK: Unable to examine MSK/EXTREMITIES: No C/C/E. No e/o joint swelling or erythema. SKIN: Pale. No rashes, jaundice, cyanosis. NEURO: Somewhat hypotonic. Does awaken slightly and move head.

Differential Diagnosis?
7 day old female with respiratory failure and hypotension.

Differential Diagnosis
ID
Pertussis RSV Enterovirus Sepsis
GBS E. coli Listeria Enterococcus

FEN/GI
TE fistula GER Viral hepatitis

CV
HLHS Aortic coarctation Truncus arteriosis TAPVR Transposition of the great arteries Pulmonic atresia/stenosis Tricuspid atresia Aortic stenosis Tetralogy of Fallot DILV

Neuro
Seizures

Pulm
RDS Pulmonary hemorrhage

HSV TORCH Pneumonia

Chlamydia GBS Aspiration

Other
NAT DIC

Labs/Work-up
CMP - BUN 3, Cr 0.29, Albumin 1.4, Bilirubin 4.3, Alk. Phos. 56, ALT 100, AST 260 UA 1+ glucose, neg LE, nitrite, ketone, protein, Hgb PTT - 36 PT/INR: 17.2/1.4 Fibrinogen: 165 Serum HSV PCR pos CSF HSV PCR pos Tracheal aspirate HSV pos Conjunctival swab HSV pos

Neonatal HSV - Epidemiology

Incidence 1 in 3,000 to 1 in 20,000 live births Risk greater with primary infection Esp when acquired close to delivery Transmission most commonly direct contact with infected vaginal secretions Increased risk with longer ROM Transmission can also occur in utero or post-natally 3 types
Skin, Eyes, Mouth ~45% CNS disease ~33% Disseminated ~25%

Skin, Eye, Mouth HSV

Present ~10-12 days of life High rates of progression to CNS or disseminated if not treated Clustering vesicular lesions with erythematous base Eye infection usually asymptomatic but may have watering, crying from eye pain, conjunctival erythema

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CNS HSV
2nd-3rd week of life Presentation: Seizures, lethargy, irritability, tremors, poor feeding, temp instability, full anterior fontanelle, DIC, apnea, shock Diagnosis: CNS normal or with mononuclear cell pleiocytosis and elevated protein 60-70% will have skin lesions

Disseminated HSV
Usually present in 1st week of life Can involve: Adrenals, CNS, eye, liver, lung, mouth and skin
60-75% have CNS involvement Skin vesicles are usually late finding and 20% do not have any skin manifestations Serious complications severe coagulopathy, liver dysfunction, pulmonary involvement

Mortality >80% if untreated

Diagnosis
HSV PCR on blood, CSF and specimen from skin vesicle Viral Culture Swab specimens from mouth, nasopharynx, conjunctiva, anus Specimens from skin vesicles and CSF Most cultures will grow within 5 days Whole blood measurement of ALT

Treatment
Prevention
C-section for women with lesions resembling HSV Avoid scalp monitors in women with HSV lesions

High dose Acyclovir (60 mg/kg/day div q8hrs) for at least 21 days (14 days for SEM) Ocular involvement topical 1% trifluridine, 0.1% iododeoxyuridine or 3% vidarabine

Suppressive therapy: 6 months of oral acyclovir 3,000 mg/m2 Improves neurologic outcomes in CNS disease Prevents skin recurrences in all classifications

Outcomes
Mortality
29% for Disseminated HSV 4% for CNS HSV

Percent of survivors with normal neurologic development

98% for SEM 83% for disseminated 31% for CNS

References
Thompson, C and R Whitley. Neonatal Herpes Simplex Virus: Where are We Now? Advances in Experimental Medicine and Biology. 2011; 697: 221-230. Robinson, JL, Vaudry, WL, Forgie, SE, et al. Prevention, recognition and management of neonatal HSV infections. Expert review of anti-infective therapy. 2012; 10(6): 675-685. Uptodate. Neonatal Herpes Simplex Virus Infection.
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