Pediatric emergency medicine trisk 1450 1450
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may be evident. A bulging or tense fontanel may be found if meningitis is
present. Otitis media, abdominal rigidity, joint swelling, tenderness in one
extremity, or chest findings such as rales indicate the infection has localized. Soft
tissue infections from MRSA are becoming a more common cause of sepsis.
Always examine the neonate for signs of omphalitis, an ascending infection
originating in the umbilicus. Finally, if the disease process has progressed, the
infant may develop shock and hypotension.
The laboratory is often helpful in suggesting a diagnosis of sepsis; however,
definitive cultures require time for processing. Potential abnormal laboratory
studies include a complete blood count (CBC) with a leukocytosis or leukopenia
with left shift, a coagulation profile with evidence of DIC, and blood chemistries
with hypoglycemia or metabolic acidosis. Recent risk stratification criteria utilize
elevated c-reactive protein (CRP) and procalcitonin (PCT) to identify infants at
high risk for serious bacterial infection. If localized infection is suspected,
aspiration and Gram stain of urine, joint fluid, spinal fluid, or pus from the middle
ear may reveal the offending organism, and a chest radiograph may show a lobar
infiltrate if pneumonia is present. Cerebrospinal fluid (CSF) cultures are
diagnostic for meningitis, and polymerase chain reaction (PCR) tests for CSF are
now readily available to screen for the most common viral and bacterial
etiologies. A promising new approach, in development, is the identification of
differing host mRNA response patterns to specific pathogens, which can be
determined more quickly than waiting for culture results.
Other Infectious Diseases
Overwhelming viral infections may cause systemic inflammatory response
syndrome (SIRS) and sepsis (see Chapter 10 Shock ). Approximately, 25% of
infants younger than 1 month with enteroviral infections develop sepsis, with
high mortality. Respiratory distress, hemorrhagic manifestations of the
gastrointestinal tract and skin, seizures, icterus, splenomegaly, congestive heart
failure, and abdominal distention often occur. Viral isolates from stool and CSF or
enterovirus PCR of the CSF may confirm the offending enterovirus.
Epidemics of respiratory syncytial virus (RSV) occur in the wintertime,
leading to respiratory distress, cyanosis, or apnea. Premature infants or those with
previous respiratory or cardiac disorders are especially susceptible to apnea.
Knowledge of illness prevalence in the community and wheezing on chest
examination may lead to the suspicion of RSV bronchiolitis. Some infants
develop wheezing later in the course, making the initial diagnosis in these
patients difficult. A rapid nasal wash test for RSV will be quickly diagnostic, and
a more expensive respiratory viral panel will diagnose other viral pathogens
