Index of Suspicion in the Nursery

A 10-day-old Hispanic female neonate is brought to the emergency department with a 1-day history of vomiting, poor feeding, and tactile fever. The emesis has been nonbilious and projectile and occurred 5 to 15 minutes after feedings. There is no history of diarrhea, rhinorrhea, jaundice, rash, cough, or cyanotic events. A sibling living in the household had been sick with gastroenteritis. The baby had been delivered at term by lower segment cesarean section because of a previous cesarean section, was appropriate for gestational age, and had an uneventful immediate neonatal period. On physical examination, the baby is alert and well hydrated. Her heart rate is 176 beats/min, respiratory rate is 50 breaths/min, temperature is 100.4°F (38°C), and oxygen saturation is 98%. No jaundice, pallor, rashes, or organomegaly are evident, and the abdomen is soft and nondistended with normal bowel sounds. A complete septic evaluation is undertaken, including a complete hemogram, a comprehensive metabolic profile, a chest radiograph, cerebrospinal fluid (CSF) analysis, and cultures of blood, urine, and CSF. The baby is admitted after initiating antibiotic therapy to rule out sepsis. Following admission, parenteral antibiotics are continued, and the baby is monitored with serial examinations and follow-up of cultures. Baseline laboratory test results are unremarkable, and the cultures remain sterile. Significant abdominal distention develops on the second hospital day. The abdomen is tender, with hepatomegaly and decreased bowel sounds. An abdominal radiograph shows a large soft-tissue mass in the epigastric region displacing …