Neonatal meningitis complicating with pneumocephalus
A 7-day-old male newborn was brought to the casualty with complaints of refusal to feed and progressive increase in head size for the last 3 days. In view of his critical condition, the baby was immediately put on ventilator with supportive management. History revealed that though the mother had received two doses of tetanus toxoid during the second trimester of pregnancy, and rest of her antenatal period was also uneventful, the baby had been home delivered wherein a blade and the common home thread had been used for cutting and tying the umbilical cord. The baby had cried immediately after birth and was on breastfeeding since then, but he started refusing feed from the fourth day onwards, besides a gradual increase in the head size. On examination, the baby was hypothermic, pale, and had an enlarged head (39 cm). The umbilical cord had fallen on the 5th day of life, but the area showed signs of inflammation. His heart rate was 130/min, respiration was irregular, and capillary refill time (CRT) was >3 seconds. His blood glucose was 33 mg/dL. Results of the laboratory investigations done on his blood were as follows: Hemoglobin (Hb) - 13.9 g/dL, total leukocyte count (TLC) - 6.800 × 103/μL with neutrophils (N) 75% and lymphocytes (L) 25%, platelets - 85 × 103/μL, C-reactive protein - 20 mg/dL, total serum bilirubin - 8 mg/dL (direct 4 mg/dL), urea - 20 mg/dL, creatinine - 0.8 mg/dL, sodium - 142 mmol/L, potassium - 5.6 mmol/L, prothrombin time - 30 s (control - 15 s), and activated partial thromboplastin time 42 s (control - 30 s). In view of the enlarged head, bulging anterior fontanel and widely spaced cranial bones, congenital hydrocephalus, intraventricular hemorrhage, septicemia with meningitis, and battered baby syndrome were thought of as possible conditions. As his neurosonogram showed air like densities, a plain computed tomography (CT) scan of brain was done which revealed diffuse pneumocephalus along with large amount of air in subdural and subgleal spaces, besides showing hemorrhages and meningeal enhancement in the region of posterior fossa []. The diagnosis was clear now, that we were dealing with a case of meningitis with pneumocephalus and there was hardly any other possible differential diagnosis.\nA lumbar puncture (LP) was then done and his cerebrospinal fluid (CSF) examination showed cells - 550/μL (with N - 85%, L- 15%), glucose - 35 mg/dL, and protein - 228 mg/dL; the CSF and blood cultures were negative. In view of his critical condition, the baby was put on vancomycin (20 mg/kg/dose q8h, intravenous (IV)), meropenem (40 mg/kg/dose q8h, IV) along with supportive management. An attempt to decompress tension pneumocephalus was also made by putting an 18 G needle in subgleal plane, from which air came out under pressure. However, despite all this, the condition of the baby failed to show any improvement and he succumbed within 48 h of being brought to the hospital.