Case Presentation: 6 day old full term male presented with one day of fever and irritability. Birth history significant for maternal fever during delivery (with sick contact just prior to delivery) and 48 hours of antibiotic therapy prior to discharge from the nursery. Exam only significant for fever and irritability. Given concern for meningitis, workup included blood, urine and cerebrospinal fluid (CSF) cultures along with herpes simplex virus (HSV), influenza and enterovirus testing. Urinalysis was reassuring. CSF studies demonstrated no organisms on gram stain, elevated protein (234 mg/dL), normal glucose; total nucleated and red blood cells could not be determined due to specimen clotting. Initial blood work demonstrated thrombocytopenia (47,000/uL), mildly elevated transaminases (AST 160 iU/L and ALT 61 iU/L), and mildly elevated prothrombin time (16.2 s). Empiric cefotaxime, ampicillin and acyclovir were started. Irritability improved, however, he required multiple platelet transfusions (nadir of 14,000/uL). At 48 hours, blood, urine and CSF cultures along with HSV studies were negative. Enterovirus PCR was positive from CSF, nasopharyngeal, and rectal samples, and antimicrobials were discontinued. On day 3 of hospitalization, he rapidly deteriorated developing hypoxia then signs of shock. He required intubation and significant inotropic support. The constellation of maternal fever during delivery, age at presentation, persistent thrombocytopenia, hepatitis, coagulopathy, and development of heart failure from acute myocarditis established the diagnosis of vertically transmitted enterovirus. Due to severity of condition and potential benefits, he was given 2 doses of intravenous immunoglobulin. Ultimately, respiratory and inotropic support were weaned off, enterovius viral loads down trended, cardiac function improved, and follow up outpatient echocardiogram had normal ventricular function.
Discussion: Neonatal enterovirus infection, specifically when vertically transmitted, has a high risk for morbidity and mortality. Enterovirus in the newborn can cause a range of disease with severe disease consisting of hepatitis, coagulopathy, pneumonia, myocarditis, meningoencephalitis and sepsis. Frequent symptoms include fever, irritability, rash and anorexia. Severe disease is associated with maternal illness prior to or at delivery, illness onset within the first few days of life and prematurity.
Conclusions: Differential for an ill appearing febrile neonate includes more than bacterial or HSV infection. Hospitalists often encounter enterovirus infections, which are usually relatively innocuous, but keen clinical acumen and a high degree of suspicion is needed to detect disseminated vertically transmitted enterovirus that can be life-threatening. And although, no specific treatment exists, awareness through anticipation of complications leads to timely supportive care at facilities with appropriate level resources to potentially minimize adverse outcomes.