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Washington University Experience | VASCULAR | Hemorrhage - Neonatal | 25A0 Case 25 History
Case 25 History ---- The male baby was born by C-section at 24 weeks EGA to a 33 year old G3P1 mother. Apgars at delivery were 1 at 1 minute and 6 at 5 minutes. The patient was intubated and found to be anemic, acidotic, hypoglycemic and hyperkalemic. Within 24 hours the patient's abdomen was distended and tense and hematocrit fell from 38 to 19. Abdominal ultrasound revealed peritoneal fluid in the abdomen and an emergent laparotomy was performed on 3/22 at which time multiple small lacerations of the liver and spleen were discovered and repaired. A post-op ultrasound of the head showed a left intraventricular hemorrhage with midline shift. Several days later, repeat ultrasound of the head showed an increase in ventricular size and a large volume of blood in the ventricular system and left frontal lobe. On 3/28 the patient began to develop generalized seizures lasting up to 3 minutes, treated with phenobarbital and Dilantin. On 4/1 a blood culture was positive for candida treated with Amphotericin B for candidiasis. On 4/6 LP showed protein 389, cell count 4500 with 110 white blood cells. CSF cultures were positive for candida, but were largely uninterpretable due to blood contamination. Repeat head ultrasound again showed left intraventricular hemorrhage, left intraparenchymal hemorrhage with a left greater than right ventricular hydrocephaly. The patient continued to have seizures. On 4/8, the patient had the acute onset of respiratory distress, bradycardia, hypotension, fever, and metabolic acidosis consistent with sepsis. Blood cultures eventually grew Enterococci. An increasingly distended abdomen became suspicious for necrotizing enterocolitis. Given the patient's poor prognosis, the patient's family and medical team elected to extubate the infant. The patient expired on 4/8. ---- At autopsy subacute periventricular hemorrhage of the left side of the brain was confirmed as well as Candida granulomas correlating with the documented premortem Candidal sepsis. In addition, focal bowel ischemia with muscular wall atrophy and necrosis as well as transmural acute and chronic inflammation was found. Culture of liver tissue grew Candida. The kidneys showed focal abscess formation with detection of Candida type organisms, consistent with the clinically documented Candidial septicemia. The right lateral ventricle was compressed, the left lateral ventricle was distended by extensive subependymal hemorrhage overlying the thalamus and the basal ganglia with partial organization. ---- All of neuropathology brain sections showed multifocal micro-granulomas with epithelial histiocytes and multinucleated giant cells with GMS identified Candida type organisms. ---- 25A1 A coronal section of this immature brain shows SEGM hemorrhage, extension into the ventricle and causing left sided hydrocephalus.
