Infant develops painless swelling around her ears
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A healthy 12-day old female seems to suddenly develop painless bilateral swelling of both the preauricular areas and the right postauricular area. There is no fever or other concerning symptoms, and her appetite is normal and unchanged.
The mother’s pregnancy, labor and delivery were complicated by having a positive group B strep (GBS) screening culture, and she received two doses of penicillin G more than 4 hours prior to delivery.
The baby’s vital signs are normal, and the only abnormal finding on exam is the painless soft tissue swelling described earlier, and as shown in Figures 1 through 3. Even though the baby has dark skin, no appreciable erythema is seen. Due to the baby’s age and presenting complaint, she had a full sepsis workup, with normal results on cerebrospinal fluid (CSF), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), complete blood count (CBC) and complete metabolic profile. However, at 24 hours, a blood culture obtained in the ED is growing both gram-positive cocci in clusters and gram-negative rods. Imaging with ultrasound reveals no collection of fluid consistent with an abscess, and an MRI is pending. The baby had cefotaxime, gentamicin and vancomycin treatment empirically started in the ED after the culture was obtained.
Summary:
- A previously healthy, 12-day-old female presents with painless, bilateral soft tissue swelling about both ears.
- The infant is afebrile, feeding well and well-appearing.
- She has normal sepsis workup screening lab tests, with a positive blood culture for gram-positive cocci and gram-negative rods.
- Ultrasound shows no abscess, only soft tissue.
What’s your diagnosis?
A. GBS sepsis and erysipelas
B.Staphylococcus aureus cellulitis
C. Mixed Escherichia coli and strep sepsis with cellulitis
D. None of the above
The answer is D, none of the above. This case describes a well-appearing neonate with no fever and who is feeding well. She has unexplained bilateral areas of soft, painless swelling about the face and neck, with a normal CSF, CBC, ESR, CRP and chemistries, but it is complicated by a positive blood culture with two organisms. The MRI revealed three complex venolymphatic malformations (Figures 4 and 5), and the blood culture grew coagulase-negative Staphylococcus and Acinetobacter baumannii, which were considered to be contaminates. A repeat blood culture was negative. However, one might argue that the patient had a negative repeat blood culture because the antibiotics were working. This is where experience and clinical judgement come into play, considering the preponderance of laboratory and clinical evidence, especially after the results of the MRI were known. Also, none of the antimicrobials listed would be expected to work against A. baumannii. Due to a high rate of resistance, the first drug of choice for this organism is usually a carbapenem, pending sensitivity results. Both groups A and B streptococcus can cause sepsis and erysipelas in neonates (Figures 6 and 7), and a venolymphatic malformation may look similar, making it difficult to discern the clinical difference, especially in a neonate.
Clinical experience can be obtained only through practice over time, and clinical judgement has always been somewhat difficult to teach, but it also comes with practice and common sense. A septic baby is likely to appear clinically sick (irritable, lethargic, poor appetite, dehydrated, etc.) with some abnormal screening lab tests on the sepsis workup. However, as all pediatric residents learn very quickly, a septic neonate may not look sick, even to the most experienced examiner. Therefore, clinical judgement should not take the place of a full sepsis workup in a neonate if there is any reasonable doubt. Such was the case with this baby in the ED. It was also appropriate to empirically begin treatment with broad-spectrum antimicrobial therapy pending culture results and clinical course progression. One could argue in favor of a variety of empiric antimicrobial combinations, but in a situation like this, it would be prudent to empirically cover for strep, staph and E. coli. With that combination, other organisms are likely to be covered as well, pending culture results.
Lastly, the mother’s positive GBS screen is significant, but with two doses of penicillin G given at least 4 hours prior to delivery, the chances of early-onset GBS disease is very low. However, prophylaxis has no significant effect on the incidence of late-onset GBS disease, which, by definition, is when a GBS infection occurs beyond 7 days of age. Since this patient was 12 days of age, the fact that the mother received penicillin during labor would not be expected to make any difference in the decision-making process.
Columnist Comments:
I hope your new year is off to a good start. Please let me know if you see opportunities for improvement in this column. Even though I have been writing it for over 33 years, I always feel that I could do better. Also, if you have an interesting case with a publishable picture, and would like to participate as a g uest c olumnist, just let me know. I particularly enjoy helping residents get in on the act. I hope to see you out there soon, with mask off.
For more information:
Brien is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health and an adjunct professor of pediatrics at Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at jhbrien@aol.com.