Meningitis most likely diagnosis

Features of meningitis in infants include many of the following symptoms and signs:

Symptoms: lethargy, restlessness, paradoxical irritability, high-pitched cry or a vacant stare, altered feeding pattern, diarrhea, and vomiting.

Signs: apnea, tachypnea, hypothermia or hyperthermia, bradycardia on general survey; nystagmus, opisthotonos, seizures, altered tone, nuchal rigidity, and bulging fontanelle on neurologic exam; jaundice, cyanosis, petechiae, livedo reticularis, and purpura may be visible, along with a delayed capillary refill time. Abdominal distention may also be present.

In this scenario, the infant has paradoxical irritability, altered feeding pattern, hyperthermia, bulging fontanelle, petechiae, and a delayed capillary refill time. In an infant less than 2 months of age, with the symptoms presented in this case, the most likely diagnosis is meningitis until proven otherwise by further testing.

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed.

Chapter 168 - Neurologic Disorders. David H. Rubin, Edward E. Conway Jr., Stuart M. Caplen, Jonathan I. Singer, Dina Halpern Kornblau.

Multiple Choice

1. The correct answer is (C) Mongolian spots

Mongolian spots are more common among darker-skinned babies. They range from bluish-gray to deep brown or black. They disappear after a few years and usually fade by puberty.

Response (A) is incorrect. Café au lait spots are characteristically light-brown pigmented lesions, which usually have a ragged border. Response (B) is also incorrect. Salmon patch or stork bite lesions are splotchy pink in color and are often found on the back of the neck and the back of the head of infants. They fade with age. Neurofibromatosis is incorrect as well. Early findings in neurofibromatosis include more than five café au lait spots and axillary freckling. Later findings include neurofibromas and Lish nodules.

2. The correct answer is (B) Erythema toxicum

Erythema toxicum consists of yellow or white pustules, which are surrounded by a red base. The rash is scattered diffusely over the infant's body and frequently changes location. The palms and soles are often spared.

On the other hand, neonatal acne consists of red pustules and papules, which are most prominent over the cheeks and nose of the newborn infant. Seborrhea is a salmon-red, scaly eruption, which often involves the face, neck, axilla, diaper area, and the area behind the ears. Jaundice refers to the yellow-orange discoloration that appears on a newborn infant's skin. If it appears on the second day of life and is slow to spread, then it is most likely physiologic and will resolve on its own. If it appears right at birth, then other causes of jaundice must be suspected and worked up.

3. The correct answer is (B) This infant has some nervous system depression

An Apgar score that is between 5 and 7 at 1 minute of life indicates some nervous system depression.

A normal Apgar score at 1 minute of life is between 8 and 10. An Apgar score of 0-4 at 1 minute of life indicates severe depression, requiring immediate resuscitation. An Apgar score at 5 minutes of life that is between 0 and 7 indicates that the infant is at high risk for subsequent central nervous system and other organ system dysfunction.

4. The correct answer is (D) Neonatal meningitis

Neonatal meningitis is a significant infection, which can result in significant developmental delay.

Although chronic otitis media may cause a delay in speech and language development, it occurs in children older in age than 6 months. A single episode of otitis media does not result in developmental delay. Overfeeding is obviously an incorrect response since this infant is well within range for weight and has no sign of overfeeding, which, in any case, does not result in significant developmental delay. Nor is gastroesophageal reflux a correct answer since it does not result in developmental delay.

5. The correct answer is (C) 20/40

Children under 4 years of age have an expected visual acuity of 20/40.

Eyes converging is an expected finding in children aged 0-3 months. This patient is 2 years old. The second response (-20/200) is incorrect; this is an expected finding in children who are 12 months of age. The fourth response (20/30) is likewise incorrect. Children over the age of 4 have an expected visual acuity of 20/30.

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