Question-

. Question-1

A 24-week-gestation infant was born in good

condition and was ventilated at birth. He received

two doses of surfactant 12 h apart. His mother had

received two doses of betamethasone 24 h before

delivery. His ventilatory requirements stabilised

and he was weaned off the ventilator on day 5 onto

CPAP. He was given antibiotics (benzyl penicillin

and gentamicin) for 48 h, which were then stopped,

as blood cultures were negative. He was started on

small amounts of feed on day 4 (breast milk,

0.5 ml/ 4 h), which were gradually increased.

On day 6, he developed recurrent apnoeas and

bradycardia. He was on an appropriate dose of

caffeine.

1.    What is your differential diagnosis?

2.What investigations would you perform?

The child’s symptoms worsened and he needed

ventilation. He had a distended, tender and

shiny abdomen and his nasogastric aspirates

were dark green. Blood tests showed a raised

white cell count and an elevated level of Creactive

protein (CRP). His blood gas showed

metabolic acidosis. An abdominal X-ray showed

intramural bowel gas.

3. What is your main diagnosis?

4. What investigation and management steps will

you undertake?

On day 10 he underwent surgery. On the 4th

post-operative day, his CRP went up and his

blood gas deteriorated. He did not handle well.

He was noticed to have multiple subcutaneous

nodules over his thighs and arms. He had a

peripheral intravenous canula and a long line in

situ. He was on cefotaxime, vancomycin and

metronidazole.

5. What type of infection do you suspect?

6. How will you treat him and what is your plan for

further management?

Answer 1

1. Differential diagnosis is:

(a) neonatal sepsis

(b) necrotising enterocolitis

 (c) patent ductus arteriosus

(d) intraventricular haemorrhage

(e) apnoea of prematurity.

2.

The necessary investigations are:

(a) Blood gas to assess acid base status and

consider ventilation.

(b) Septic screen including lumbar puncture (LP).

(c) Examine the abdomen and if there are any

concerns request an abdominal X-ray and

consider stopping feeds.

(d) Feel for bounding pulses and hyperdynamic

precordium, listen for murmurs and arrange

a cardiac assessment.

(e) Cranial ultrasound scan.

3. (a) Necrotising enterocolitis (Bell’s stage 2).

Bell’s staging criteria:

_ Stage 1: Suspected NEC: non-specific symptoms,

feed intolerance, gastric residues, occult blood,

apnoea, lethargy, temperature instability, bradycardia.

X-ray normal or non-specific.

_ Stage 2: Definite NEC: mild to moderate illness.

Signs similar to stage 1 and prominent abdominal

distension, absent bowel sounds, abdominal

tenderness, metabolic acidosis and thrombocytopenia.

X-ray showing pneumatosis, dilated

loops and may present with portal venous gas.

_ Stage 3: Advanced NEC: severely ill. Respiratory

and metabolic acidosis, disseminated intravascular

coagulation (DIC), hypotension, coagulopathy,

tense discoloured and distended

abdomen. X-ray showing absent bowel gas and

possible pneumoperitoneum.

4. Stop feeds, keep nil orally, insert nasogastric

tube with free drainage and start on antibiotics

for 7–10 days.

5. Fungal infection, especially following gut surgery.

6. Systemic antifungal therapy in appropriate

dosage. Amphotericin is the recommended drug

in this scenario. LP needs to be done to look for

CNS involvement, as flucytosine may be needed

for better CNS penetration. Removal of the long

line is essential. Also, need to perform ECHO,

renal ultrasound scan and ophthalmic examination

to rule out fungal involvement at these

sites. Antifungal treatment should be for a

minimum of 21 days