1 - Serviço de Pediatria, Unidade Local de Saúde Arco Ribeirinho, Barreiro
2 - Unidade de Cuidados Intensivos Pediátricos, Pediatria Médica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
3 - Unidade de Infecciologia, Pediatria Médica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
4 - Serviço de Otorrinolaringologia, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
5 - Unidade de Neurologia, Pediatria Médica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
6 - Neurocirurgia, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
7 - Unidade de Cuidados Intensivos Pediátricos, Pediatria Médica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
- Reunião Internacional, comunicação oral “Meet the expert” 42nd anual metting of the European Society for Pediatric infectious diseases.
Resumo:
Introduction: Neonatal hypotonia is a common finding with a wide differential diagnosis to consider. Perinatal and birth history, and a careful physical examination help to distinguish between systemic illness or central nervous system vs. peripheral nervous system dysfunction. In newborns presenting bilateral upper limb hypotonia cervical spine lesions should be considered.
Case presentation summary: 21-day-old neonate observed for asymmetric Moro reflex. The mother had lived in S. Tomé up to 25 weeks of pregnancy, which was uneventful, and labour was induced at 38 weeks for oligoamnios. Within 7 days she presented bilateral upper limb hypotonia, lower limb hypertonia, absent Moro and grasp reflexes and diminished spontaneous movements. Parents referred impaired weight gain, but denied fever, impaired alertness and history of trauma. MRI revealed C2-C6 spondylodiscitis with medullar compression and a huge prevertebral abscess which compressed the trachea. Laboratory findings showed leucocytosis (31390/uL) and elevated C reactive protein (220mg/L). The newborn was transferred to the Paediatric Intensive Care Unit, ventilated for the risk of airway obstruction, and initiated with empirical cefotaxime and clindamycin. Methicillin-sensitive Staphylococcus aureus was isolated in the blood and aspirate cultures, the histology was compatible with a pyogenic abscess and antibiotics were switched accordingly. Mantoux skin test and molecular amplification of Mycobacterium tuberculosis were negative, still waiting for culture. A tracheostomy was performed for the prolonged need of ventilation, and cervical immobilization was assured by cervical collar. She completed 4 weeks of co-trimoxazole and 6 of flucloxacillin with reduction of the abscess and improvement of the neurological deficits. Anterior dislocation of the C5 vertebral body persisted, with probable need for future surgical fixation.
Key Learning Points: We present an extremely rare neonatal case of cervical spondylodiscitis complicated by prevertebral abscess, medullar compression and vertebral dislocation. Exclusion of TB is crucial. Prolonged treatment with antibiotics and cervical immobilization are essential to prevent sequelae. In this case surgery will probably be needed.