Index of Suspicion in the NurseryCase 1: Term Neonate With Hypotension and RashCase 2: Persistence of Newborn Scrotal Masses

A 3.7-kg, 6-day-old term infant presents to the emergency department with decreased oral intake, irritability, and respiratory distress. No history of fever, or respiratory or gastrointestinal symptoms are elicited. Prenatal and delivery history are unremarkable, including negative maternal serologies and Group B streptococcus testing. Mother is healthy, but the sibling has rhinorrhea and cough. The infant is intubated for respiratory distress, receives 60 mL/kg of normal saline boluses for poor perfusion, and dopamine is started for hypotension. The infant is noted to have a blanching, maculopapular erythematous rash involving the axilla and trunk, but otherwise has a nonfocal physical examination. A sepsis evaluation is performed, including blood, urine, and cerebrospinal fluid (CSF) cultures. Empirical antimicrobial therapy with ampicillin, gentamicin, and acyclovir is administered, and the infant is transferred to the NICU for further management. A 6-week-old healthy boy presents with bilateral painless scrotal swelling. He was born at term via normal vaginal delivery following an uneventful pregnancy; antenatal ultrasound scans were normal. The scrotal mass had been present since birth and initially was believed to be a hydrocele but it had become firmer over a course of 6 weeks. On physical examination, it consisted of two small, grape-size swellings, one above the left testis and one below the right testis. There was no history of delayed passage of meconium or any sign of bowel obstruction. Plain abdominal radiograph was performed and did not show intra-abdominal calcifications. An ultrasound scan demonstrated that both testes were normal in size, shape, and echodensity. Within the right and left scrotum there were paratesticular masses of mixed echogenicity. Both masses could be traced toward the inguinal canal, as shown in Fig 1. There were no abdominal calcifications. Sweat test and tissue culture were performed to exclude cystic fibrosis and tuberculosis, respectively, and were negative. …