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A Persistently Fussy, Febrile Infant

A 4-day old female infant, born at term, presented to an outside hospital emergency department (ED) with a 12-hour history of fever and fussiness. She was born to a 20-year-old, group B streptococcus negative, primigravid mother at a community hospital via caesarian section secondary to maternal fever and abdominal pain. The mother was febrile for 48 hours prior to delivery; blood and urine cultures were negative. She was diagnosed with chorioamnionitis and taken for urgent caesarian section. Per the hospital report, rupture of membranes was at the time of caesarian section. The infant did well in the delivery room; Apgars were 8 and 9 at 1 and 5 minutes, respectively, and the birth weight was 2852 g. The infant had one episode of hypothermia (34.8°C) in the immediate postnatal period. Two blood cultures were drawn and she was treated empirically with ampicillin and gentamicin for 48 hours. She was well-appearing throughout her hospital stay; antibiotics were discontinued when cultures were negative at 48 hours, and she was discharged home with her mother on day of life (DOL) 3. At the time of discharge she was formula feeding well, with no temperature instability. On DOL 4, the mother reported that the infant had fed poorly in the morning and was fussy with an irregular cry. Mother took an axillary temperature of 101.0°F, so she brought the infant to the ED. In the outside hospital ED, the infant was noted to be 101.3°F; the remainder of the vital signs were normal. Physical examination revealed a fussy but consolable infant. The anterior fontanelle was soft and flat, and the infant’s tone, Moro, suck, and grasp reflexes were normal. Laboratory workup in the outside ED included complete blood count, electrolytes, urinalysis, and cultures of the blood, urine, and cerebrospinal fluid (CSF). The white blood cell count was 11.4 × 10/mL (reference range 5.0 to 19.5), with 15% bands and 72% granulocytes; hemoglobin was 14.0 × 10/mL (reference range 12.5 to 20.5), and platelets were 304 × 10/mL (reference range 150-450). Urinalysis and electrolytes were unremarkable. The lumbar puncture was reportedly traumatic, with 5900 red blood cells and 2 white blood cells per high-powered field. CSF glucose was 55 mg/dL (reference range 40 to 75) and CSF protein was 66 mg/dL (reference range 15 to 45). The infant was started empirically on ampicillin and gentamicin and transferred to our facility for inpatient care.