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Rare Diagnosis in a Neonate Who Presents With Fever

An otherwise healthy 3-week-old African American male presented to a pediatric emergency department with a 1-day history of fever and tachypnea. He had been in his usual state of health until the day prior to presentation, when he developed a temperature of 38.9°C and mild respiratory distress. His mother reported increased fussiness, but he continued to feed well and maintained good urine output. She denied any other symptoms or any medication use. His only sick contact was a 10-year-old cousin who had an upper respiratory infection. He was born at term via uncomplicated cesarean delivery to a primigravid mother. He had an uncomplicated nursery course and was circumcised prior to discharge. Initially, no significant family history was reported. The patient lives with his mother and does not attend daycare. On physical examination, his vitals revealed temperature of 39.7°C, heart rate of 163 beats per minute, respiratory rate of 30 breaths per minute, blood pressure of 88/51 mm Hg, and oxygen saturation of 95% on room air. He was alert and appeared in no distress. His lung, cardiac, abdominal, skin, and neurological examinations were all within normal limits. Blood, urine, and cerebrospinal fluid (CSF) were obtained. Initial erythrocyte sedimentation rate was 23 mm/h. Complete blood count revealed a leukocytosis of 20.9 × 10 cells/mm, with a differential of 31% segmented neutrophils, 31% bands, 23% lymphocytes, 10% monocytes, 2% eosinophils, and 3% reactive lymphocytes. Urinalysis was normal. CSF analysis revealed 1 red blood cell/mm and 8 white blood cells/mm, with a differential of 3% segmented neutrophils, 13% lymphocytes, 82% monocytes, and 2% macrophages. CSF glucose was 50 mg/dL, and protein was 26 mg/dL. CSF enterovirus polymerase chain reaction and respiratory viral panel were both negative. Chest radiographs revealed opacities in the right upper and middle lobes, and lingular regions that were most compatible with multifocal pneumonia. The patient was empirically started on intravenous ampicillin 200 mg/kg/d and intravenous cefotaxime 200 mg/kg/d while awaiting the results of blood, urine, and CSF cultures.