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Washington University Experience | VASCULAR | Hemorrhage - Neonatal | 10A0 Case 10 History
Case 10 History ---- The decedent was born at 29 weeks EGA. His mother received prenatal care and had normal serologies but was GBS positive (penicillin Rxed). Rupture of membranes with discolored bloody discharge preceded a vaginal delivery. He had Apgars of 4, 6, and 7 at 1, 5 and 10 minutes. He was intubated and given surfactant then extubated to CPAP. He did reasonably well for one week until he developed worsening apnea and bradycardia. Caregivers initiated a sepsis workup and started vancomycin and gentamicin. Blood and urine cultures were positive for E coli. A head ultrasound showed a stable grade I subependymal hemorrhage. A new murmur prompted an echocardiogram study, which showed a large patent ductus arteriosus and patent foramen ovale with significant right to left shunting. He was intubated 12/14 and blood gases showed worsening metabolic acidosis. Continuous EEG monitoring showed seizures, uncontrolled for 48 hours, despite adding levetiracetam therapy. Antibiotics were switched to cefotaxime and vancomycin for CSF coverage, and on 12/16 the cephalosporin was switched to cefepime to broaden coverage. He developed DIC with falling hemoglobin and platelets treated with packed RBCs, platelets and fresh frozen plasma. On 12/17 MR imaging with contrast showed a large cerebellar hemorrhage, intraventricular hemorrhage and infarcts in periventricular white matter. Pupils were fixed and dilated. The family decided to redirect care, and he was extubated and passed away within 15 minutes. ---- At autopsy the unfixed brain weight was 230 gm (normal 191 +/- 33 gm). Large patchy areas of subdural and subarachnoid hemorrhages involved all lobes bilaterally. The cerebellar hemispheres show hemorrhagic destruction of a majority of the cerebellum. Coronal sections of the cerebral hemispheres show bilateral germinal matrix hemorrhages with associated intraventricular blood filling a majority of the bilateral lateral, third, and fourth ventricles. There is punctate paraventricular discoloration of the white matter. Transverse sections of the brainstem show global discoloration with patchy petechial hemorrhages. Horizontal sections of the cerebellum show severe bilateral tissue loss with associated hemorrhage. The external surfaces of the spinal cord has green tinge and the cut surfaces have a somewhat gelatinous appearance. ---- Sections showed that left frontal and occipital lobes were involved by subarachnoid hemorrhage, acute meningitis, extensive apoptotic cortical neurons (or eosinophilic neuronal necrosis), and white matter infarction characterized by vacuolation, pallor, astrocytosis, macrophages and microglial proliferation as well as periventricular infarcts and calcifications. Sections of the left basal ganglia show germinal matrix hemorrhage extending into the ventricles with ependymal disruption. The portions of cerebellum which were not destroyed, show Purkinje neuron apoptosis, astrocytosis, pallor, vacuolation, increased microglial proliferation, and subpial hemorrhage with associated macrophages.
