A 29-day-old Infant with Poor Feeding and a Rash.

1. DeAnna J. Friedman-Klabanoff, MD* 2. James D. Campbell, MD, MS* 1. *Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 1. Address correspondence to DeAnna Friedman-Klabanoff, MD, University of Maryland School of Medicine, Center for Vaccine Development and Global Health, 685 W Baltimore St, Room 480, Baltimore, MD 21201. E-mail: defriedman{at}som.umaryland.edu At postnatal day 29 in early April, a female infant presents to an outside emergency department with her mother because of poor feeding. Her mother states that she just noticed a new area of redness and a lump on her neck as she was taking the infant out of her car seat (Fig 1A). She had no fevers at home. Her mother states that she was born at 34 weeks’ gestation via cesarean delivery due to prolonged premature rupture of membranes. During her 2-week stay in the NICU, she had bradycardia spells, but no need for intubation or antibiotics. No one in her family has been ill before her presentation. Figure 1. (A) Appearance of cellulitis upon presentation to the outside emergency department and (B) 4 hours later upon arrival to our pediatric intensive care unit. On initial assessment, the infant is lethargic and ill appearing with intermittent apnea and oxygen desaturations down to 80%, eventually requiring intubation. On physical examination, she has an area of well-circumscribed erythema overlying her right sternocleidomastoid muscle with underlying indurated nodules. She receives 30 mL/kg of normal saline for tachycardia and delayed capillary refill, and intravenous ampicillin and cefotaxime for presumed sepsis. Her white blood cell count is 10.8 × 103 cells per microliter with 60% segmented neutrophils and 28% bands. Her complete blood cell count is otherwise unremarkable. Her C-reactive protein is 121 mg/L. She is transferred to a tertiary referral hospital for further evaluation and management. On arrival to the PICU, she is hypothermic to 93.2°F (34°C). She undergoes lumbar puncture. The cell count shows 8 white blood cells per high-power field, which …