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- Rishi Mediratta, MD, MSc, MA*
- Hayden Schwenk, MD, MPH†
- Anoop Rao, MD‡
- Ritu Chitkara, MD, FAAP‡
- *Department of Pediatrics,
- †Division of Pediatric Infectious Diseases, and
- ‡Division of Neonatal-Perinatal Medicine, Stanford University School of Medicine, Stanford, CA
AUTHOR DISCLOSURE
Drs Mediratta, Schwenk, Rao, and Chitkara have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
Presentation
A 6-week-old girl is admitted to the NICU with liver dysfunction and jaundice. One week before presentation she had developed an erythematous macular rash on the chest and extremities, oral thrush, and a low-grade fever. Physical examination reveals jaundice, hepatosplenomegaly, and a desquamating macular rash on the left lower extremity. Her vital signs are normal for age. She was born to a 34-year-old G7P2321 woman via normal spontaneous vaginal delivery at 37 weeks' gestation. Birthweight was 3,060 g (35th percentile). The infant’s mother had routine prenatal care, and her course was complicated by intrahepatic cholestasis of pregnancy. Results of first-trimester maternal Treponema pallidum enzyme immunoassay were negative.
Laboratory evaluation reveals acute liver failure, coagulopathy, conjugated hyperbilirubinemia, lymphocyte-predominant leukocytosis, disseminated intravascular coagulation, anemia, and thrombocytopenia. Laboratory test results are notable for hemoglobin level, 7.2 g/dL (72 g/L); total leukocyte count, 25,000/μL (25.0 × 109/L) with 68% lymphocytes and 18% neutrophils; platelet count, 20 × 103/μL (20 × 109/L); aspartate aminotransferase, 1,164 U/L (19.4 μkat/L); alanine aminotransferase, 536 U/L (8.9 μkat/L); albumin, 1.8 g/dL (18 g/L); international normalized ratio, 1.8; and partial thromboplastin time, 34.9 seconds. Her C-reactive protein level was elevated at 19.1 mg/L (181.9 nmol/L).
Discussion
The differential diagnosis includes sepsis due to bacteria such as Escherichia coli, Enterococcus, Klebsiella, methicillin-resistant Staphylococcus aureus, and T pallidum. Potential viral pathogens include enterovirus, echovirus, adenovirus, parvovirus, Epstein-Barr virus, cytomegalovirus, herpes simplex virus (HSV), human immunodeficiency virus (HIV), human herpesvirus 6, and other viral hepatitides. Noninfectious possibilities include α1-antitrypsin deficiency, hemophagocytic lymphohistiocytosis, and acetaminophen toxicity.
Treatment with vancomycin, …
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