- 1.1 Superficial Infections
- 1.2 Systemic Infections
- 1.3 Congenital Infections
- 1.4 Miscellaneous
Section Outline
- 1.1 Superficial Infections
- • Acute Otitis Media
- • Bacille Calmette-Guérin Abscess
- • Breast Abscess
- • Cellulitis
- • Conjunctivitis
- • Gangrene
- • Impetigo
- • Neonatal Scabies
- • Oral Thrush
- • Pustules
- • Umbilical Sepsis
- 1.2 Systemic Infections
- • Brain Abscess
- • Necrotizing Enterocolitis
- • Neonatal Candidiasis
- • Neonatal Osteomyelitis
- • Neonatal Meningitis
- • Pneumonia with Pneumatoceles
- • Sclerema Neonatorum
- • Septic Shock
- • Staphylococcal Scalded Skin Syndrome
- 1.3 Congenital Infections
- • Congenital Cytomegalovirus
- • Congenital HIV
- • Congenital Rubella Syndrome
- • Congenital Syphilis
- • Congenital Toxoplasmosis
- • Congenital Tuberculosis
- • Neonatal Chickenpox
- • Neonatal Tetanus
- 1.4 Miscellaneous
- • Hand Washing
- • Sepsis Screen
Picture | Note | Management |
1.1 SUPERFICIAL INFECTIONS
Acute Otitis Media
Note the purulent discharge in the external ear. It may be isolated or part of sepsis syndrome. Irritability, incessant crying, and feeding difficulty may be the only manifestations. Fever may or may not be there (Fig. 1.1.1). |
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Bacille Calmette-Guérin Abscess
Note the pus formation at Bacille Calmette-Guérin (BCG) site. There is no er ythema, discharge or local warmth. The newborn is otherwise well and manifests 1–5 months post vaccination (Fig. 1.1.2). At times there may be ulceration and lymphadenopathy. |
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Breast Abscess
Note the redness and fullness of the left breast (Fig. 1.1.3). This is usually associated with warmth, local tenderness and fluctuation with no discharge. History of squeezing milk from the nipple is often present. | Incision and drainage, analgesics and antibiotic therapy is required. |
Cellulitis
Note the bluish blackish discoloration of skin over the back with adjoining erythema, edema and skin induration extending on to neck with patchy areas of ulceration and necrosis (Fig. 1.1.4). Signs of worsening such as increasing redness or swelling or foul-smelling drainage from the affected area warrant surgical consult. |
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Conjunctivitis
Note the bilateral pur ulent eye discharge with partial ability to open the eyes. This is usually associated with conjunctival congestion. Watery discharge with no conjunctival congestions is seen in dacrocystitis. Gonococcal conjunctivitis tends to be more severe than any other causes of ophthalmia neonatorum (Fig. 1.1.5). |
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Gangrene
Note bluish blackish discoloration of fingers, palms, hands extending up to the elbow. There is overlying induration, hardening and necrosis with clear line of demarcation with healthy skin (Fig. 1.1.6). With underlying severe sepsis embolus, thrombosis and/or coagulopathy predispose to gangrene formation. Arterial thrombosis, emboli, trauma, congenital heart disease, coagulopathy, polycythemia, congenital bands, and birth trauma are some of the causes which should be considered. |
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Impetigo
Note multiple superficial lesions over the chin with adjoining erythema and crust formation (Fig. 1.1.7). It is highly contagious and is primarily caused by Staphylococcus aureus. |
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Neonatal Scabies
Note the macules, papules and vesicles over the foot and the web spaces (Fig. 1.1.8). There is a tendency to form pustules early in the course of illness. Such lesions are also seen over the face, neck, scalp, and palms. Eczematization and impetiginization are common. History of scabies in one of the family member or care taker is often present. |
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Oral Thrush
Note the whitish, curdy plaques over the tongue, buccal mucosa and the soft palate (Fig. 1.1.9). These lesions bleed on scrapping and cannot be removed easily. The newborn presents with feeding difficulty. |
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Pustules
Note multiple pustules in the periumbilical area. There is surrounding erythema (Fig. 1.1.10). They may also be present over the trunk, axilla, and g roins. At times, there may be induration, hardening of the adjoining skin with pus discharge. Many a times the newborn is asymptomatic. |
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Umbilical Sepsis
Note the visible periumbilical erythema and induration. These are suggestive of umbilical sepsis. This is usually associated with local warmth, pus discharge and foul smell (Fig. 1.1.11). There may be nonspecific signs such as fever, irritability, feeding difficulty or respiratory distress. It may remain localized or can quickly progress to sepsis and present as a potentially life threatening condition. Underlying umbilical polyp should be looked for. |
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1.2 SYSTEMIC INFECTIONS
Brain Abscess
Note a single, large space occupying lesion in frontal lobe with surrounding edema with minimal shift of midline with no dilatation of ventricles (Fig. 1.2.1). These arise as a complication of septicemia, meningitis or underlying systemic cause for thrombosis or embolism. Presence of unexplained high fever, lethargy, seizures, focal deficit, worsening sensorium should raise suspicion of brain abscess. Any new born baby with acute pyogenic meningitis who is not responding to routine treatment should be screened for complication like subdural empyema, brain abscess, etc. |
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Necrotizing Enterocolitis
Note the preterm baby has abdominal distension which is tense with overlying shiny abdominal skin. There are yellowish brown gastrointestinal (GI) aspirates (Fig. 1.2.2). These features suggest necrotizing enterocolitis (NEC). The NEC is primarily a disease process of the GI tract of preterm that results in inflammation and bacterial invasion of the bowel wall. |
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Neonatal Candidiasis
Note the ashen gray complexion in a sick, preterm baby. A slow evolving infection with risk factors like prolonged antibiotics, ventilation, prolonged ICU stay, total parenteral nutrition (TPN), invasive lines and procedures predispose to Candida infection (Fig. 1.2.3). Unexplained thrombocytopenia, cholestasis, oliguria, nonresponsive to antibiotics warrants screening for Candida. |
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Neonatal Osteomyelitis
Note the metaphyseal irregularity, radiolucency, periosteal reaction of proximal end of femur. There is also soft tissue swelling. There may be associated widening of the joint space, subluxation or dislocation (Fig. 1.2.4). Clinical symptoms include poor feeding and/or irritability. There may be a history of swelling or failure to move the affected limb (pseudoparalysis). |
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Neonatal Meningitis
Note the extensor posturing with retraction of neck. Accompanying features include seizures, temperature instability, episodes of apnea or bradycardia, hypotension, feeding difficulty, tense fontanelle and irritability alternating with lethargy (Fig. 1.2.5). Constellation of these signs should raise suspicion of meningitis. |
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Pneumonia with Pneumatoceles
Radiograph shows bilateral patchy infiltration of both lung fields more so in the right lung. Multiple air filled cavities of different sizes are seen in the left lower lobe suggestive of pneumatoceles (Fig. 1.2.6). Pneumonia complicated by pneumatocele formation is commonly due to staphylococci, Klebsiella and E. coli. |
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Sclerema Neonatorum
Note the newborn is sick, ventilated with ET in situ, with signs of poor perfusion. The skin appears shiny, taut with fullness of extremities (Fig. 1.2.7A). On pinching the skin there is hardness with inability to lift the skin between fingers due to edema and thickening of subcutaneous tissue suggestive of sclerema (Fig. 1.2.7B). The signs initially appear over the thigh and may progress to mask like facies, diffuse woody to stony hard induration of extremities, with restricted joint mobility, temperature instability and poor respiratory efforts. Onset of sclerema heralds poor prognosis. |
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Septic Shock
Note the dusky palms and soles, with patchy bluish discoloration of both hands and legs. There is associated tachycardia, drowsiness, prolonged capillary refill time (CRT), cold extremities with warm trunk, oliguria and hypotension suggestive of septic shock on clinical examination (Fig. 1.2.8). |
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Staphylococcal Scalded Skin Syndrome
Note the generalized exfoliation of skin. Manifestations include erythematous, bullous skin lesions over face, back and extremities with peeling of skin on contact (Nikolsky sign) (Fig. 1.2.9). Desquamation subsides by 48 hours of appropriate therapy. Skin lesions heal without scarring. Such exfoliation is most commonly seen due to staphylococcal infection. |
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1.3 CONGENITAL INFECTIONS
Congenital Cytomegalovirus
Note the CT brain shows calcification which are along the subependymal ventricular region (Fig. 1.3.1). Periventricular calcifications with small head are a clinical clue to cytomegalovirus (CMV) infection. Clinical features include growth retardation, thrombocytopenia, anemia, hepatosplenomegaly, neurological problems such as poor tone and seizures. |
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Congenital HIV
Note the CT brain study shows discrete calcifications in the basal ganglia. There is no evidence of loss of gray-white matter differentiation or ventricular dilatation. Progressive leukoencephalopathy with atrophy of brain is characteristic of congenital HIV infection (Fig. 1.3.2). Clinical manifestation includes failure to thrive, hepatosplenomegaly, chronic diarrhea, thrush and recurrent bacterial infections. |
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Congenital Rubella Syndrome
Note that both eyes are hazy with enlarged cornea. Intraocular pressure is increased suggesting buphthalmos. Presence of microcephaly, congenital heart defect such as PDA, growth retardation, sensorineural hearing loss is hallmark of rubella infection (Fig. 1.3.3). |
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Congenital Syphilis
Note the right upper limb in extended posture with paucity of spontaneous movement suggestive of pseudoparalysis (Fig. 1.3.4). Associated hepatosplenomegaly, epitrochlear lymph node and irritability should raise suspicion of congenital syphilis. Clavicle fracture (swelling or palpable break) or brachial plexus injury (absent grasp) also present with monoparesis. |
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Congenital Toxoplasmosis
Note the CT brain showing evidence of diffuse calcification in the periventricular region and adjacent brain parenchyma (Fig. 1.3.5). Congenital toxoplasmosis is more likely with diffuse calcification and large head. Associated features include hydrocephalus, chorioretinitis, convulsions, hepatosplenomegaly, anemia and rash. |
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Congenital Tuberculosis
Note the chest X-ray shows diffuse miliary shadows all over the lung fields (Fig. 1.3.6). Clinically respiratory distress with hepatosplenomegaly should raise suspicion of congenital tuberculosis. |
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Neonatal Chickenpox
Note the erythematous rash on face and trunk. The rash assumes vesicular form on red base and spread over trunk and limbs. There is evidence of cr usting in some lesions with pleomorphism which is diagnostic of chickenpox (Fig. 1.3.7). |
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Neonatal Tetanus
Note the neonate has retracted neck (retrocollis) and complete arching of the back (opisthotonus). There is associated mask like facies with inability to open mouth (trismus). Opisthotonus and stimulus induced spasms with intact sensorium is hallmark of tetanus (Fig. 1.3.8). | Treatment is essentially supportive, minimal stimulation, sedatives, muscle relaxants, anticonvulsants, penicillin and tetanus immunoglobulin. |
1.4 MISCELLANEOUS
Hand Washing
The picture depicts cleaning of the hands with the use of water and soap under an elbow operated tap. Hand washing involves systematic hand motions in six steps to done before entering the nursery (2 min) and after each contact with the patient (Fig. 1.4.1). The purpose is to remove soil, dirt, and/or microorganisms from hand surfaces. Center for Disease Control (CDC) recommends it as one of the most important measures for preventing the spread of pathogens. |
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Sepsis Screen
Picture depicts commonly used kits for screening for neonatal infection– EDTA (For CBC, ANC, I:T ratio, platelet count), micro tubes (uESR), plain bulb (CRP) or qualitative CRP kit and blood culture broth (Fig. 1.4.2). |
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