PALE STOOL: AN ATYPICAL PRESENTATION OF NEONATAL SEPSIS

Abstract

Introduction

Sepsis remains a leading cause of morbidity and mortality among neonates. Late-onset sepsis (LOS) is neonatal sepsis occurring after 72 hours of life, which can be fatal if misdiagnosed and left untreated. Here we report a case of neonatal LOS.

Case Description

A baby boy at day-27 of life, who was born late preterm; presented with fever, reduced oral intake, abdominal distension, and passing pale stool for one day. Upon assessment, the baby was lethargic, jaundiced, tachycardic, dehydrated with cold peripheries, and his abdomen was distended. He was diagnosed with biliary atresia in sepsis and the paediatric team was immediately alerted. His blood results revealed leukocytosis and severe metabolic acidosis. His X-ray showed large bowel dilatation with no pneumoperitoneum. He was given boluses of intravenous (IV) crystalloids, put on nasal flow oxygen, inserted a nasogastric tube for bowel decompression, and started on IV cefotaxime and metronidazole. He was put on IV fluid maintenance with strict urine output monitoring and started with nasal high flow oxygen therapy in the Paediatrics Intensive Care Unit. Ultrasound of his hepatobiliary system showed no evidence of biliary atresia. His C-reactive protein was raised and his urine culture grew Enterococcus faecalis. The baby responded well and was discharged after a week. 

Discussion

The risk of LOS is high in premature and low-birth-weight neonates, with non-specific manifestations. A high index of suspicion combined with diagnostic tests including inflammatory markers, blood and urinary cultures, and radioimagings are necessary to identify the source of sepsis. Optimization of airway, breathing, circulation, disability, and exposure (ABCDE) plus early referral are the cornerstone of management. Neonates with apnea or respiratory distress should be intubated and oxygen therapy is necessary to optimize tissue oxygenation. Judicious IV fluids should be administered to maintain tissue perfusion whilst early empirical antibiotic therapy and prevention of hypothermia and hypoglycemia must be ensured during neonatal resuscitation. 

Conclusion

LOS in neonates requires a high suspicion index, prompt neonatal resuscitation, and early referral to ensure the best outcome and prevent mortality.