Citrobacter koseri meningitis and septicemia in a neonate with borderline fever at home.

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From: CMAJ: Canadian Medical Association Journal(Vol. 193, Issue 41)
Publisher: CMA Impact Inc.
Document Type: Clinical report
Length: 2,339 words
Lexile Measure: 1880L

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A 13-day-old boy presented to the pediatric emergency department with a chief complaint of fussiness and shivering overnight. The patient felt hot to his parents' touch; his axillary temperature, measured at home, was 37.7[degrees]C while bundled and was 37.5[degrees]C a few hours later when unbundled, which prompted the visit. The baby continued formula feeding frequently, but with slight decreases in volume, and was stooling and voiding appropriately (> 6 full diapers in the preceding 24 h). He was somewhat sleepy, but easily rousable and consolable with his parents.

At triage, the patient's vitals were within age-appropriate ranges, with a rectal temperature of 37.4[degrees]C, respiratory rate of 48 (normal 40-60) breaths/min, oxygen saturation 98% on room air, heart rate 152 (normal 100-160) beats/min and blood pressure 82/50 mm Hg. His weight at presentation was 3.44 kg; birth weight was 3.25 kg. Clinical examination was otherwise unremarkable; specifically, he had normal tone, brisk perfusion, no neck stiffness, no rash and a level fontanelle. We did not identify any overt sources of infection on examination.

The patient had been born at 38+3 weeks' gestation via normal vaginal delivery to a seroprotected, transmasculine father (assigned female at birth). The father had vaginal colonization of group B Streptococcus (GBS) and type 2 diabetes mellitus requiring insulin during pregnancy. Pregnancy was also complicated by a chlamydia infection in the third trimester that was treated with unknown antibiotics and confirmed resolved with a negative result on retest before delivery. Birth was uncomplicated, with appropriate peripartum prophylaxis with GBS penicillin, and routine monitoring for hypoglycemia. The newborn was discharged 24 hours after birth with no concerns. We noted no other risk factors for early neonatal sepsis; specifically, prolonged ruptured membranes, previous infant with GBS meningitis or maternal fever.

Considering the reported axillary temperature higher than 37.5[degrees]C at home, we conducted a full septic workup, consisting of blood culture, viral nasopharyngeal swab, urine culture and lumbar puncture with cerebrospinal fluid (CSF) analysis. We admitted our patient and treated him empirically with intravenous ampicillin, cefotaxime (both at 50 mg/kg) and acyclovir (20 mg/ kg) pending culture results. Results of investigations are presented in Table 1.

Given abnormal CSF results, we increased the antibiotic dose to meningitis doses at 100 mg/kg/dose for both ampicillin and cefotaxime. Ten hours after presentation, we recorded a rectal temperature of 39.0[degrees]C. Laboratory values worsened over the next 24 hours to a peak white blood cell count of 18.8 * 109/L, C-reactive protein of 48.2 mg/L and venous lactate of 4.1 mmol/L. The blood culture returned positive for Citrobacter spp., and we changed the patient's antibiotics to meropenem on the advice of our microbiologist. Polymerase chain reactions of CSF for herpes simplex virus, enterovirus and parechovirus were negative, and cultures of both blood and CSF grew Citrobacter koseri.

Our patient's fevers stopped after 4 days of antimicrobial therapy. He did not have any seizures and his neurologic status did not worsen during the admission. Initial cranial ultrasound and follow-up magnetic resonance imaging did not show any...

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Gale Document Number: GALE|A678710296