Female newborn, 38 weeks gestation, LGA, birth weight 3.510 gr and height 50 cm. Apgar 9-10, second daughter of healthy parents.
She was born by elective cesarean section due to a previous cesarean section.
The mother had a history of a physiological pregnancy, a urinary infection in the first trimester of pregnancy and detection of vaginal-rectum Streptococcus agaia in the third trimester of pregnancy.
He started at 25 days of life, myoclonic movements of the left hemibody while awake; the mother noticed loud sounds and decreased demand for food.
She was taken to the emergency department for evaluation.
Upon admission, the patient was febrile, in relative good general conditions, with no abnormal movements, jaundice with normal tension, absence of lesions in the skin and mucous membranes, and segmental examination was normal.
Vital signs: HR 177 per min, RR 52 per min, T° 38.3° C axillary, P. arterial stenosis 55 mm/Hg, mean arterial pressure 62 mm/Hg, O2 saturation 97%.
Initial laboratory tests: leukocytes 6,800/mm3 (52% lymphocytes), hematocrit 40.7%, CRP: 0 mg/L, biochemical profile with mild hyperbilirubinemia of indirect predominance.
Urine output and chest X-ray were normal.
Upon observation in the emergency department, the patient presented irregular breathing, irregular skin, and myoclonic movements in the right hemibody, which did not surrender to the patient with mental disorder.
Oxygen support, isotonic saline solution (Cl 9%) 20 ml/kg bolus, lorazepam 0 was indicated for her clinical condition.
1 mg/kg i.v., starting empirical antimicrobial treatment with ampicillin + cefoxime i.v., then obtaining blood cultures and CSF samples.
The cytochemical analysis of CSF was normal and direct Gram staining did not show the presence of bacteria Table 1.
An additional ml of CSF was stored at 4°C for further molecular biology studies.
1.
She was admitted to the Neonatal Intensive Care Unit for monitoring her condition.
Twenty-four hours after admission, the patient developed fever, hyporeactivity, and an episode of gaze fixation with recurrent focal seizure.
The possible diagnoses were acute initial meningitis or an encephalopathy for which the CSF study was repeated and it was decided to add antimicrobial therapy, bacterial meningitis iv.
60 mg/ kg/ day
Cytochemical analysis of the second CSF revealed the presence of 190 leukocytes/mm3 with mononuclear predominance (79%), 170 erythrocytes/mm3, normal glycorrhachia and proteinorrhachia.
Direct Gram stain did not show the presence of bacteria (2; Table 1).
A qualitative CSF PCR was requested for HSV types 1 and 2 (herpes simplex virus 1/2 Real Time PCR kit, InsideGen® Bioscan, Chile) without achieving viral DNA detection.
Despite the negative result of RT-PCR 24 h after the onset of the clinical picture, treatment was continued with indinavir 1. v. since the patient presented consciousness compromise and focal seizures.
A brain CT scan, on the second day of hospitalization, was normal, and the electroencephalogram showed diffuse hypovoluted slowness and occasional multifocal acute paroxysms.
Phenobarbital 15 mg/kg iv and then 5 mg/kg/day were administered as a bolus dose.
Bacteriological cultures of the first and second CSF and blood were negative.
Erythema multiforme Erythema multiforme Erythema nodosum Stevens- Johnson syndrome (potentially life- threatening) Toxic epidermal necrolysis (potentially life- threatening)
Liver and kidney functions were normal, as well as evaluation.
Persistent seizure manifestations until the third day of hospitalization.
From then on, he was alert, with vigorous suction, without new crises, highlighting only a tremor syndrome of the left upper limb.
Brain MRI performed on day 10 of hospitalization showed hyperintense subcortical lesions in the bilateral peri-rolandic, frontomedial and right insular region, with focal leptomeningeal meningeal findings.
Upon obtaining the result of positive RT-PCR for HSV 1, the mother was re-interrupted carefully who told her that her father had a lip eruption suggestive of herpes labialis two weeks before the child became ill.
After 20 days of treatment, the antiviral CRL was controlled, resulting in negativity of the PCR for HSV 1 and 2 in CSF.
Twenty-one days later, the patient developed seizures, without complications.
Since discharge, the patient was systematically controlled in the Infectious Diseases and Child Neurology Polyclinics.
In our last evaluation, at 5 months of life, a eutrophic infant was found with a significant delay in psychomotor development.
