Radiologic, Neurologic and Cardiopulmonary Aspects of Submersion Injury.

Many indices and scores are used in critical care medicine to aid management and predict risk of mortality. We report 2 cases of submersion injury and discuss the usefulness and application of common respiratory and critical care indices. The respiratory indices help better understand the pulmonary pathophysiology and characterize the severity of lung injury and ventilation/perfusion mismatch. Severe lung injury resolved after ventilation support with appropriate positive end-expiratory pressure in both cases. The 6-year-old girl survived the near-fatal submersion injury intact despite grossly abnormal initial Glasgow Coma Scale (GCS) and high Pediatric Index of Mortality 2 scores, whereas the 5-year-old boy with grossly abnormal GCS and Pediatric Index of Mortality 2 scores died despite resolution of lung injury. These cases illustrate that resuscitation should be promptly instituted at the scene to ensure optimal outcome because initial pulmonology and neurology indices may not reliably predict mortality or intact survival. The GCS score was not initially designed for prognostication. Nevertheless, 2 serial GCS scores of 3, one performed at emergency department and one at the pediatric intensive care unit, were associated with nonsurvival in our second patient.

Late Onset Streptococcus agalactiae Meningitis following Early Onset Septicemia: A Preventable Disease?

We report a neonate who presented with early onset Streptococcus agalactiae or group B streptococcus (GBS) septicemia within 24 hours of birth. After discharge at day 14, she went on to develop late onset GBS meningitis at 36 days of age. The infant was treated with intravenous antibiotics on both occasions and eventually discharged home with no apparent sequelae. We address issues associated with GBS infection in infancy including the demographics, risk factors, and the risk of late onset GBS meningitis following an early onset GBS infection. The major source of GBS in early onset GBS disease is maternal birth canal GBS colonization. On the other hand, nosocomial cross-infection is an important source of GBS in late onset disease. Penicillin remains the current treatment of choice for GBS infection. Given the rapid onset and progression within hours of birth and lack of an effective solution for preventing late onset GBS, administration of an effective GBS vaccine in pregnancy could provide a sensible and cost-effective solution in all settings.

Spot diagnosis: An ominous rash in a newborn.

Purpura fulminans (PF) is an ominous cutaneous condition usually associated with meningococcemia. PF in the newborn is rarely reported. We report the case of a female preterm infant with extensive PF due to group B streptococcus (GBS) septicemia. She developed multi-organ system failure despite neonatal intensive care support and succumbed 9 days later. GBS, sensitive to penicillin, was isolated from the blood cultures of the mother and the infant. Invasive early GBS infection is common in the newborn and is empirically treated with prompt institution of intravenous antibiotics. PF associated with GBS is a rare cutaneous sign that must not be missed. Mortality remains high despite aggressive treatment and ICU support.