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Washington University Experience | VASCULAR | Hydrocephalus, Post-Hemorrhagic | 4A0 Case 4 History
Case 4 History ---- The patient was admitted to St. Louis Children’s Hospital (SLCH) in March, 1978 on his first day of life. The patient was a 1280 gm estimated 30 week gestational product of a 22 year old gravida 1 and was the 3rd baby of a triplet pregnancy, complicated only by nausea and, at 30 week checkup, the cervical os was noted to be 5 cm dilated. The mother was then admitted to the hospital on Terbutaline for 5 days, unfortunately she went into spontaneous labor. The APGARs at birth were 5/6 and the baby was cyanotic. On admission to SLCH, the head circumference was 27~ cm, length 39~ cm, the anterior fontanelle was soft and flat, sutures were slightly overlapped. The child was in respiratory distress with retractions and rales. On neurologic exam, the patient had poor tone throughout. There were few spontaneous movements, but the baby only moved weakly to stimulation with a weak suck and grasp. The patient had bilateral upgoing toes. Deep tendon reflexes were l+ throughout. Extraocular movements were intact to OCM's. Posture was in partial flexion and the Moro reflex was absent. Over the next several days on 100% oxygen, the hyaline membrane disease seemed to gradually improve. An LP was done initially for the workup of possible sepsis and hematocrit on the CSF from was 15%, dropping to 10% over the next week. Daily LPs were done as therapy for possible development of hydrocephalus. However, during the procedure the patient had a heart rate drop and responded to brief bagging and stimulation. Later that day the baby seemed more lethargic and the heart rate decreased again and the baby was cultured for possible sepsis and started on Gentamicin and Methicillin. Over the next 3 days, the major medical problems were hypocalcemia treated with intravenous calcium drip, rule out sepsis, rising BUN, and persistent problem with respiratory distress syndrome. An enlarged liver was also noted to the level of the umbilicus. An EKG was normal for age and an echocardiogram showed a large left atrium suggestive of a moderate to large left to right shunt. Impression was a probable patent ductus arteriosus with heart failure. The baby was then started on Digoxin. The bilirubin continued to increase and on 4/3/78, it was a total bilirubin of 21, direct of 12.8. The BUN continued to increase over the next several days to a total of 29.8 and a direct of 11.6. Viral and toxoplasma titers of CMV, herpes, rubella and coccidio B were all normal. Lesions on the skin which were black, hemorrhagic, and necrotic especially on the chest and extremities were noted. Impression was vasculitis possibly due to sepsis. The baby at this time was still being treated with Gentamicin and Methicillin. The baby died on the 24th day of life. All blood cultures were reported as no growth.
