428 Emergency Medicine
women and to treat at the time of delivery for either screen positive women
or women with fever or PROM. Any infant under 4 weeks with fever
greater than 100.3°F(and most would say any infant under 8 weeks)
requires a full workup to search for the source of infection.This work-
up includes a CBC, blood culture, urinalysis and urine culture, and a lumbar
puncture for cell counts and culture. Many people recommend sending the
CSF for herpes simplex virus (HSV) culture and polymerase chain reaction,
particularly if there are any maternal risk factors or suspicious skin lesions,
or in any infant who is very ill.
The other organisms listed are all known causes of neonatal sepsis but
less likely than GBBS. Escherichia coli(a)is the second most common
pathogen and is the most common of the enteric pathogens that cause this
condition. It is the most common cause of UTIs in infants, which can lead to
bacteremia as well. Listeria(b)is a commonly cited source of infection in
neonatal sepsis. Exposure is primarily from unprocessed meats and unpas-
teurized produce. Staphylococcus aureus(d)is an unlikely pathogen in an
immunocompetent patient this age. HSV (e)is an important pathogen to
consider in neonatal sepsis. Obtaining the maternal history is important to
help diagnose this condition, though many patients who ultimately are diag-
nosed with neonatal HSV have no known maternal history of vaginal herpes.
The lesions on this patient’s trunk are most consistent with a benign newborn
rash called erythema toxicum neonatorum and are unrelated to the fever.
385.The answer is d.(Fleischer and Ludwig, p 774.)This is a case of
Guillain-Barré syndrome (GBS).GBS is characterized by progressive,
symmetric muscle weakness, typically beginning caudally and progress-
ing cephalad.It is also associated with reduced or absent deep tendon
reflexes.It is thought to be a postinfectious condition (viral illnesses in the
preceding weeks are reported in the majority of cases) that is pathologically
characterized by acute demyelination. It is typically self-resolving but can be
treated by IVIGor even plasmapheresis in severe cases.Care is supportive,
which may ultimately involve mechanical ventilation in cases where paralysis
ascends to involve respiratory muscles. A variant of GBS is known as Miller
Fisher disease in which there is predominant involvement of facial nerves.
There is no specific serologic test for GBS but lumbar puncture is typically
performed and demonstrates increased protein with no pleocytosis.
MRI of the spine (a)would be most useful and important in cases of
suspected transverse myelitis or a space occupying lesion. This case is not