SESSION TYPE: Infectious Disease Student/Resident Case Report Posters III
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: A 5-week old septic female infant with culture proven omphalitis complicated by overwhelming SIRS response while on antibiotic therapy. Her course resembled an overlap between atypical Kawasaki disease and Sweet’s syndrome. She initially responded to IVIG and NSAIDs, ultimately required systemic steroids for evidence of continued inflammation.
CASE PRESENTATION: A 5 week old female infant with no significant medical history transferred from community hospital after clinically worsening on antibiotic therapy for presumed cellulitis and respiratory distress. Initially presented with fever, umbilical drainage, and increased work of breathing. After extension of umbilical cellulitis, persistent fevers, and development of periorbital cellulitis while receiving cefotaxime, clindamycin and acyclovir added and patient transferred for further evaluation. Hospital Course: Antibiotic coverage expanded to include vancomycin and meropenem due to persistent high fevers and worsening of cellulitis despite antibiotics (Figure 1). Nonsterile skin culture from umbilicus grew Strep anginosus, Enterococcus faecium, and ESBL E. coli. Chest x-ray with persistent ill defined RUL opacity (Figure 2). Over the next 36 hours she developed erythematous plaques at sites of previous IV sticks. CRP continued to climb and fevers continued to occur multiple times daily. Cellulitic areas began to show improvement on HD#4/5 and Motrin initiated on HD#5 which improved fever curve; ultimately required supplemental O2 for 12 days. Topical steroid to affected sites initiated and biopsy demonstrated neutrophilic infiltration of the dermis, consistent with diagnosis of Sweet’s syndrome. Pt also treated for atypical Kawasaki disease with IVIG and aspirin. The patient was discharged on low dose aspirin. At initial follow-up labs demonstrated increased platelet count and rise in CRP, so patient initiated on systemic steroids in the face of ongoing inflammation. Next follow-up 6 days later showed stable platelet count, downtrending CRP, and clinically well appearing; repeat follow-up 1 week later demonstrated continued downtrending of CRP and mildly decreased platelet count.
DISCUSSION: Our initial concern was sepsis, but lack of response to broad-spectrum antibiotic therapy led to diagnosis of Sweet’s syndrome, as patient met diagnostic criteria to include neutrophilic infiltrate on biopsy and response to steroid therapy. Prolonged oxygen requirement and chest X-ray findings suggestive of neutrophilic pulmonary infiltrates.
CONCLUSIONS: The clinical presentation of an infant with SIRS criteria and suspicion for bacterial infection typically improves with systemic broad-spectrum antibiotics. In the case of an ongoing SIRS response despite appropriate antibiotic coverage, the differential expands.
DISCLOSURE: The following authors have nothing to disclose: Danika Alexander, Downing Lu
No Product/Research Disclosure InformationWalter Reed Nat'l Military Medical Center, Bethesda, MD