COMPLICATED STAPHYLOCOCCAL INFECTION IN A NEONATE. A. Ansary*, D. Varghese, L. Jackson ROYAL HOSPITAL FOR CHILDREN, GLASGOW,UK

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1 COMPLICATED STAPHYLOCOCCAL INFECTION IN A NEONATE A. Ansary*, D. Varghese, L. Jackson ROYAL HOSPITAL FOR CHILDREN, GLASGOW,UK

2 Complicated staphylococcal infection in a neonate Overview Case Radiology/biochemistry/microbiology findings Discussion Learning Points References

3 Background Baby Z Royal Hospital for Children Glasgow, Neonatal Unit 25+1 weeks gestation, Birth wt: 975g Maternal antenatal steroids Intubated at birth, surfactant administered Extubated after 24 hours Day 12 weaned to high flow nasal cannula

4 Case S. Aureus Sepsis Day 21 of life Increasing concerns regarding sepsis Re-ventilated due to increasing apnoeic events. Blood cultures, ET aspirate Positive for Staphyloccus Aureus Intravenous flucloxacillin l 14 days CRP rise to 108 Initial low WCC

5 Baby Z Pneumatocoele Improved clinically CRP, WCC normal Extubated to Biphasic CPAP on day 29 Small pneumatocoele noted on radiograph h(d (day 33) No respiratory compromise at this time

6 Radiology First Episode of S.Aureus Sepsis day 21 Pneumatocoele noted day 33

7 Baby Z Stridor Day 36 Sudden onset of biphasic stridor Increasing oxygen requirement t& work of breathing IV dexamethasone higher pressures on biphasic CPAP g p p Required re intubation stridor resolved CXR enlarging pneumatocoele on the right side with associated deviation of the major airways No clinical features of sepsis or rise in inflammatory markers

8 Radiology Day 36 Enlarging Pneumatocoele noted during stridor Post intubation

9 Restarted flucloxacillin Baby Z Repeat Blood culture negative ET secretions positive Extubated to biphasic CPAP day 40. CXR resolution of the pneumotocoele. Self ventilating in air by day 60. Dicharged day 74 No further stridor/ pneumatocoele/focal pathology Chest CT and bronchoscopy were not undertaken No further sepsis Not screened for immunodeficiency

10 Radiology Pneumatocoele Day 38 No residual Pneumatocoele Day 49

11 Laboratory C- Reactive Protein White Cell Count Episode of S.Aureus Sepsis Acute episode of Stridor

12 Microbiology STRIDOR POSITIVE S. AUREUS ET secretions Blood culture Ear swab Eye Swab POSITIVE S. AUREUS ET secretions Ear swab NEGATIVE S. AUREUS Blood culture

13 Discussion Points 1. Pneumatocoele formation in neonates 2. Stridor in neonates 3. Inflammatory marker response in pneumatocoele y p p formation

14 Discussion 1 PNEUMTOCOELES Thin walled, gas filled cysts lung parenchyma. 1 Congenital, traumatic, post infectious, hydrocarbon ingestion and ventilator induced. 2 Neonatal pneumatocoeles Baby Z mostly ventilator induced induced air leak conditions in pre surfactant era. 3,4 recent case reports post pneumonic 4 8 Positive microbiology for S. Aureus Radiology prior to S. Aureus sepsis no evidence of pneumatocoele Received surfactant & brief period of ventilation

15 Discussion 2 STRIDOR Biphasic stridor severe, fixed airway glottis, subglottis or trachea Can be caused by bronchogenic cysts, vascular rings compressing trachea resulting in stridor in neonates Bacterial tracheitis age group 4 6 years. Staphylococcus aureus common causative agent, stridor due to laryngeal 9 oedema. 9 Baby Z CXRandthetimeline timeline oftheevent event possible etiology pneumatocoele To our knowledge, this is the first reported case presenting with stridor. Noobviousedema obvious, membrane ordifficulty notedduringduring intubation. Minimal intubations during admission. Trialled with airway aydose of dexamethasone e aso e no response. se

16 Discussion 3 INFLAMMATORY MARKERS Inflammatory marker rise expected during acute and ongoing sepsis with persistent pneumatocele. 13 Positive endotracheal culture is a frequent finding and correlates with persistence of pneumatocele. 13 Baby Z Initial inflammatory marker rise Blood culture negative and inflammatory marker episode Positive endotracheal aspirate could have been anearly warning of a focal pulmonary pathology despite an improving inflammatory marker.

17 Learning Points In extremely preterm infants with S. aureus sepsis, pulmonary complications may arise during the recovery phase. S. aureus is well recognised dto cause pneumatocoeles which in turn can present with stridor and acute airway obstruction. bt ti Infants with S. aureus infection developing pneumatocoeles can remain clinically well with normal inflammatory markers

18 References 1. Quigley MJ, Fraser RS. Pulmonary pneumatocele: pathology and pathogenesis.ajr Am J Roentgenol 1988; 150(6): N Hussain et al, Pneumatoceles in premature infants. Journal of Perinatology 2010; 30, Clarke TA, Edwards DK. Pulmonary pseudocysts in newborn infants with respiratory distress syndrome. AJR Am J Roentgenol 1979; 133(3): Williams DW, Merten DF, Effmann EL, Scatliff JH. Ventilator-induced pulmonary pseudocysts in preterm neonates. AJR Am J Roentgenol 1988; 150(4): Glustein JZ. Enterobacter cloacae causing pneumatocele in a neonate. Acta Paediatr 1994; 83: Papageorgiou A, Bauer CR, Fletcher BD, et al. Klebsiella pneumonia with pneumatocele formation in newborn infant. Can Med Assoc J 1973;109: Bermejo VE, Gonzales ME, Martinez AM, et al. Pneumatocele as a complication of E. coli pneumonia in a newborn infant. An Esp Pediatr 1992;37: Rohana J, Lau DS, Hasniah AL, Faizah MZ, Boo NY, Shareena I. Pneumatocoele in a neonate with perinatal tuberculosis. Arch Dis Child Fetal Neonatal Ed Mar;98(2):F Pfleger A, Eber E. Assessment and causes of stridor. Paediatr Respir Rev Oct 23. pii: S (15) doi: /j.prrv Jiang JH, Yen SL, Lee SY, Chuang JH. Differences in the distribution and presentation of bronchogenic cysts between adults and children.j Pediatr Surg Mar;50(3): Stewart B, Cochran A, Iglesia K, Speights VO, Ruff T. Unusual case of stridor and wheeze in an infant: tracheal bronchogenic cyst. Pediatr Pulmonol Oct;34(4): Goswamy J, de Kruijf S, Humphrey G, Rothera MP, Bruce IA.Bronchogenic cysts as a cause of infantile stridor: case report and literature review. J Laryngol Otol Oct;125(10): Arora P et al, Pneumatoceles in infants in the neonatal intensive care unit: clinical characteristics and outcomes. Am J Perinatol Sep;30(8):689 94

19 Thank you Questions?