Entertainment

A Linear Fracture and Meningitis Associated with Non-Infected Cephalohematoma in a Neonate

Description
A Linear Fracture and Meningitis Associated with Non-Infected Cephalohematoma in a Neonate
Categories
Published
of 3
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Related Documents
Share
Transcript
  Short Communications 1  Karagol BS et al. A Linear Fracture and Meningitis … Neuropediatrics 2011; 42: 1 – 3 Neuped/0650/23.2.2011/Macmillan ■  Proof copy for correction only. All forms of publication, duplication or distribution prohibited under copyright law. ■   received 01.01.2011 accepted 15.02.2011 Bibliography DOI http://dx.doi.org/ 10.1055/s-0031-1273713 Neuropediatrics 2011; 42: 1 – 3 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0174-304X Correspondence   Belma Saygili Karagol, MD  Mesa Koru sitesi Mimoza A blok No:14 06830 Ç ayyolu Ankara Turkey Tel.: + 90 / 506 / 893 5398 Fax.: ■   belmakaragol@yahoo.com Key words   ● ▶  cephalohematoma ● ▶  linear skull fracture ● ▶  meningitis ● ▶  neonate A Linear Fracture and Meningitis Associated with Non-Infected Cephalohematoma in a Neonate and the mother and the direct and indirect Coomb ’ s test results were negative. A radio-graphic examination revealed a cephalohe-matoma on the right parietal bone ( ● ▶   Fig. 1  ). Transcranial ultrasound showed a cystic echo-genicity (compatible with a cephalohematoma) with 43 × 12 mm diameter on the right parietal calvarium and no fracture was determined. The infant was treated with phototherapy and the vacuum-assisted delivery history was thought to be responsible for the hyperbilirubinemia and cephalohematoma. He was discharged on the Þ fth day of life and was healthy until 12 h prior to hospital readmission. On the eighth day after birth, the patient was readmitted to our NICU with a fever of up to 38.7 ° C. Vital Þ ndings were stable and he was neurologically intact. The size of the cephalohe-matoma had remained the same for several days and there were no signs of local infection on hematoma or increased intracranial pressure. Other physical examination Þ ndings were also normal. Complete blood cell count, C-reactive protein (CRP) level, urine analysis, blood and urine cultures were performed and cerebro spi-nal ß uid (CSF) samples were obtained. The peripheral leukocyte count was 12 600 / mm 3  , with a di ff  erential of 72 % neutrophils, 6 % bands, 20 % lymphocytes and 2 % monocytes. CRP level was 12.8 (N: 0 – 8) mg / L. Analysis of the CSF revealed a null red blood cell but 480 white blood cells / mm 3 , with a di ff  erential of 75 % neutrophils and 25 % lymphocytes; a glucose level of 32 (N: 40 – 70) mg / dL (simultaneous blood glucose level: Introduction ▼   A cephalohematoma is de Þ ned as a subperiosteal accumulation of blood beneath one or more than one of the bones in the skull. It is noted in 1 – 2 % of spontaneous vaginal deliveries and 3 – 4 % of forceps or vacuum-assisted deliveries [1] . The most common location is under the right parietal bone and may be associated with an underlying skull fracture. Anemia and hyperbilirubinemia are common complications, but cephalohemato-mas rarely become infected with either sponta-neous or underlying skull fractures. Here, we describe a neonate with a cephalohematoma complicated by a linear skull fracture and  Staphy-lococcus epidermidis  meningitis. Case Report ▼   A 3-day-old male infant was admitted to the neo-natal intensive care unit (NICU) with indirect hyperbilirubinemia. Natal history in another hos-pital included a vacuum-assisted vaginal delivery at 41 weeks gestation with a birth weight of 3 945 g. On admission, the baby was icteric and a cephalohematoma, 4 × 1.5 × 1 cm diameter was noted over the right parietal skull. He was icteric and neurologically intact and other physical examination Þ ndings were unremarkable. Total bilirubin and hemoglobin levels of the patient on hospitalization were 16 mg / dL and 15.8 g / dL, respectively. There was no major and minor blood group incompatibility between the baby Authors B. S. Karagol 1  , A. Zenc õ  roglu 1  , A. A. Kundak 1  , N. Okumus 1  , M. Aydin 1  , C. Uner 2  A ffi  liations   1  Sami Ulus Maternity, Children ’ s Education and Research Hospital, Division of Neonatology, Ankara, Turkey 2  Sami Ulus Maternity, Children ’ s Education and Research Hospital, Department of Radiology, Ankara, Turkey  Abstract ▼   We present a neonate with cephalohematoma complicated by a linear skull fracture and  Sta- phylococcus epidermidis  meningitis. Clinicians, especially neonatologists, should be aware that a cephalohematoma in the newborn infant with a history of vacuum-assisted delivery could be the srcin or trigger point of the infection either as sepsis, meningitis or osteomyelitis. The utmost importance of screening studies should be emphasized in order to be aware of the patho-genic potential of cephalohematomas.  Short Communications 2  Karagol BS et al. A Linear Fracture and Meningitis … Neuropediatrics 2011; 42: 1 – 3 Neuped/0650/23.2.2011/Macmillan ■  Proof copy for correction only. All forms of publication, duplication or distribution prohibited under copyright law. ■ 96 mg / dL) and a protein level of 192 (N: 40 – 120) mg / dL. The urine analysis were unremarkable. After septic work-up had been performed, an ampicillin and cefotaxim combination ther-apy was started empirically. Brain computed tomography (CT), on the same day, revealed a linear fracture of the right parietal bone and a 1.5 cm diameter area of extracranial soft-tissue den-sity consisting of the cephalohematoma ( ● ▶   Fig. 2  ). At the third day of hospitalization blood and CSF cultures grew  Staphylococ-cus epidermidis  . On the basis of antimicrobial susceptibility pat-terns, antibiotic coverage was modi Þ ed to cefotaxime and vancomycin. After 48 h of appropriate antimicrobial therapy, the patient had no further fever. He was discharged from NICU after 2 weeks therapy and put on a follow-up program. On follow-up examination at 4 months of age, there was a regression of diameter of ther cephalohematoma to 3 × 1 × 1 cm and it was calci Þ ed on the right parietal skull. The neurological improvement of the patient was normal. Cranial magnetic reso-nance imaging (MRI) revealed a 7 mm dural thickness, together with a cephalohematoma in the right frontoparietal concavity of the skull. An electroencephalogram (EEG) recording showed a normal pattern on 2 sides in both the wake and sleep states. At the latest follow-up on one year of age, no signs of the cephalo-hematoma were determined in the skull. The control cranial MRI was also normal. Discussion ▼   Infected cephalohematomas occur as either early onset (during the Þ rst 2 week of life) or later onset forms. In the Þ rst 2 weeks of life, cephalohematoma infection may follow bacterial septi-cemia with or without meningitis [2 – 6] . Blom et al. reviewed 27 cases of infected cephalohematomas and risk factors were pointed out as incision and aspiration of the hematoma, scalp infection, forceps delivery, septicemia and fetal scalp electrode use [2] . Late onset of infected cephalohematomas occurs in older infants with cellulitis over the involved area of the skull [7 – 10] . At the time of diagnosis, osteomyelitis as de Þ nitively determined in radiographic studies, usually attends these late presentations [1, 11] . Chang et al. analyzed the clinical characteristics of 28 newborns with infected cephalohematomas, 14 each in the early and late periods [12] . Escherichia coli  was the most common pathogen and was isolated signi Þ cantly more frequently in the late period (early period: 36 % , late period: 79 % ). 10 patients (36 % ) had other associated infections such as sepsis, meningitis and osteomyelitis. 3 of the 14 early period patients (11 % ) in this review succumbed. The authors concluded that clinicians should be aware that cephalohematoma is a potential site of infection and the incidence of associated systemic infection is high and may result in mortality. In reviews, the infecting organism most commonly reported in both early and late onset cases of infected cephalohematomas is Escherichia coli  [2, 12] . To the best of our knowledge,  Staphyloco-ccus epidermidis  has been reported once as the infecting organ-ism [2] . Although we did not aspirate the cephalohematoma,  Staphylococcus epidermidis  was the only organism identi Þ ed in both the CSF and blood cultures in our case. Furthermore, a lin-ear fracture of the right parietal bone and a 1.5 cm diameter area of extracranial soft-tissue density consisting of the cephalohe-matoma in CT screening revealed that the cephalohematoma in our case was the suspected logical source of entrance for infec-tion. Even though the local infection signs on the area of the cephalohematoma in our case had not been determined, we supposed that the skin ß ora including the  Staphylococcus epider-midis  pathogen, could have been carried to the meninx by a dural injury that was triggered with the linear skull fracture. While clinical assessment and judgement are important, radio-logical investigation has been given an important role also as an adjunct to e ff  ective and safe treatment. On imaging infants with head injury, guidelines suggest that skull radiographs have a role combined with high quality inpatient observation where CT is unavailable. However, CT is the gold standard for the detection of intracranial injury. In our case, a plain skull radiograph Þ lm could not demostrate the linear fracture in the parietal region. The CT scan taken in signs of clinical hesitations demonstrated the fracture. A small fracture as in our patient might not be visu-alized and could be missed in skull radiograph Þ lms. Clinicians, especially neonatologists, should be aware that cephalohematoma in the newborn infant with a history of vac-uum-assisted delivery could be the srcin or trigger point of the infection either as sepsis, meningitis or osteomyelitis. Besides skull X-ray Þ lms, further radiological investigation such as CT should be undertaken in these infants exhibiting the clinical Fig. 1  Plain skull X-ray Þ lm demonstrating the cephalohematoma in the parietal region. Fig. 2  CT and bone window CT scans revealing the linear fracture of the right parietal bone ( a  , b  ).  Short Communications 3  Karagol BS et al. A Linear Fracture and Meningitis … Neuropediatrics 2011; 42: 1 – 3 Neuped/0650/23.2.2011/Macmillan ■  Proof copy for correction only. All forms of publication, duplication or distribution prohibited under copyright law. ■ signs of infection. The utmost importance of screening studies should be pointed out in order to be aware of the pathogenic potential of cephalohematomas. Disclaimer : The authors report no con ß icts of interest. The authors alone are responsible for the content and writing of the paper. References 1 Kao   HC   , Huang    YC   , Lin   TY   . Infected cephalohematoma associated with sepsis and skull osteomyelitis: report of one case . Am J Perinatol 1999 ; 16 : 459 – 462 2 Blom   NA  , Vreede   WB  . Infected cephalohematomas associated with osteomyelitis, sepsis and meningitis . Pediatr Infect Dis J 1993 ; 12 : 1015 – 1017 3 Van Helleputte   C   , Dupont    V   , Barthels    S    et al  . Escherichia coli meningi-tis and parietal osteomyelitis in an infant: a rare complication of cephalohematoma . Rev Med Brux 2010 ; 31 : 57 – 59 4 Weiss   KJ   , Edwards   MS   , Hay   LM    et al  . Escherichia coli-infected cepha-lohematoma in an infant . Clin Pediatr (Phila) 2009 ; 48 : 763 – 766 5 Dahl   KM   , Barry    J   , DeBiasi   RL  . Escherichia hermannii infection of a cephalohematoma: case report, review of the literature and descrip-tion of a novel invasive pathogen CID . 2002 ; 35 : 96 – 98 6 Huang    CS   , Cheng    KJ   , Huang    CB  . Infected cephalohematomas compli-cated with meningitis: report of one case . Acta Paediatr Taiwan 2002 ; 43 : 217 – 219 7 Mohon   RT   , Mehalic    TF   , Grimes   CK    et al  . Infected cephalohematoma and neonatal osteomyelitis of the skull . Pediatr Infect Dis 1986 ; 5 : 253 – 256 8 Nightingale   LM   , Eaton   CB  , Fruehan    AE    et al  . Cephalohematoma com-plicated by osteomyelitis presumed due to Gardnerella vaginalis .  JAMA 1986 ; 256 : 1936 – 1937 9 Ghali    S   , Knox   KR  , Boutros    S    et al  . The incidence of cephalohematoma following craniofacial surgery . Plast Reconstr Surg 2007 ; 120 : 1004 – 1008 10 Fan   HC   , Hua   YM   ,  Juan   CJ    et al  . Infected cephalohematoma associated with sepsis and scalp cellulitis: a case report . J Microbiol Immunol Infect 2002 ; 35 : 125 – 128 11 Listinsky    JL  , Wood   BP   , Ekholm    SE   . Parietal osteomyelitis and epidural abscess: a delayed complication of fetal monitoring . Pediatr Radiol 1986 ; 16 : 150 – 151 12 Chang    HY   , Chiu   NC   , Huang    FY    et al  . Infected cephalohematomas of newborns: experience in a medical center in Taiwan . Pediatr Int 2005 ; 47 : 274 – 277
Search
Similar documents
View more...
Related Search
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks