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Case 2: Seizures, Apnea, Lethargy, and Persistent Hiccups in a Full-Term Newborn.

A female infant weighing 3,265 g is born to a 34-year-old gravida 10, para 8 mother, at 39 5/7 weeks of gestation. The pregnancy is complicated by maternal drug use (cocaine and tetrahydrocannabinol) and inadequately treated group B Streptococcus colonization. The infant is delivered via a precipitous vaginal delivery with concerns for placental abruption because of the removal of several large blood clots. At delivery, meconium staining of fluids is noted but the infant is vigorous, with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively.

At 14 hours after birth, the infant is first noted to have an episode of right upper extremity twitching, which soon progresses to involve both upper extremities. She also appears hypotonic and lethargic, and is noted to have episodes of apnea, bradycardia, and desaturations requiring continuous positive airway pressure. The infant undergoes a through screening for infections and is started on empirical broad-spectrum antibiotics and antiviral coverage ( Herpes simplex ). Serum glucose and electrolyte levels are normal. The infant is then transferred to a tertiary care facility for further care.

On arrival, the infant is noted to be lethargic and hypotonic with shallow breathing. She is also noted to have frequent hiccups. Capillary blood gas is notable for a pH of 7.29, a Paco2 of 64 mm Hg (8.5 kPa), and a base deficit of +4. The infant undergoes elective intubation and mechanical ventilation is started. A head computed tomography (CT) scan is obtained and the infant is placed on continuous electroencephalography (EEG) monitoring.

The head CT scan shows slightly …