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Index of Suspicion in the Nursery

A 4-day-old term female infant is being evaluated for fever, with a rectal temperature of 100.9°F (38.2°C), and an episode of oxygen desaturation to 70% while breathing room air. The mother reports that the infant had increasing fussiness. Prenatal care and delivery were within normal parameters. She denies use of illicit drugs and is unsure of her group B Streptococcus status. The infant has eight to nine wet diapers and about 10 bowel movements per day. She consumes 1 to 2 oz of regular infant formula every 3 hours. The only finding of note on physical examination is the fever. Her neck is supple and has no abnormalities. A full sepsis evaluation is performed, including a complete blood count and blood, urine, and cerebrospinal fluid cultures. Respiratory syncytial virus antigen and influenza test results are negative. Radiographs of the chest and lungs appear normal. The infant is admitted and treatment with ampicillin and cefotaxime is begun. Thirteen hours later, the infant develops respiratory distress manifesting with stridor and desaturation while breathing room air.

Physical examination at this time reveals a new cystic, moveable mass on the anterior triangle of her neck. Follow-up radiograph of the neck shows displacement of the trachea to the right. An 80% helium/20% oxygen mixture is started in the pediatric intensive care unit. Computed tomography (CT) scan of the neck and chest shows a 4.0×2.5-cm cystic lesion with an air-fluid level located in the anterior triangle of her neck slightly to the left of midline (Fig. 1). Thyroid study results are normal. Surgical removal of the cyst and histologic evaluation lead to the diagnosis.



 Figure 1. 
Computed tomography scan showing a cystic lesion with an air-fluid level in the anterior triangle of the neck.



### Hospital Course

The patient was taken to the operating room the next day for neck exploration. …