Osteomyelitis Complicating Neonatal Cephalhematoma

Abstract

Cephalhematomas are usually uncomplicated and of little clinical importance. When infection occurs, osteomyelitis of the underlying bone may ensue. The progression of clinical and roentgenographic events in our patient represent an instance of infected cephalhematoma associated with neonatal sepsis and complicated by osteomyelitis.Treatment with antibiotics alone did not eradicate the infection. Recovery followed adequate treatment by incision and drainage in addition to appropriate antibiotic therapy for four weeks.Cephal hematoma, a common form of neonatal injury, generally re¬ ceives little medical attention beyond observations for anemia, hyper¬ bilirubinemia, and fracture. Os¬ teomyelitis associated with infected cephalhematoma is not a frequent oc¬ currence. This report describes a newborn with bacteremia who developed an in¬ fected cephalhematoma and osteomy¬ elitis of the underlying parietal bone. Report of a CaseAfter a full-term gestation, a white girl, weighing 3.4 kg, was delivered to a healthy gravida-4, para-3, abortus-1, type-O, RHnegative mother on Nov 17, 1971. The anti-RH titer was 1:64 five days prior to deliv¬ ery. Low forceps were used to effect delivery after an uncomplicated labor. The Ap¬ gar score was 8 at one minute and 10 at five minutes.The placenta was large and edematous, and the cord was stained with meconium.Results of the initial physical examination revealed a vigorous infant with an edema¬ tous occiput and mild hepatosplenomegaly.The total cord bilirubin level was 5.0 mg/100 ml with a direct fraction of 1.1 mg/100 ml. Initial hemoglobin level was 10.0 gm/100 ml, and the leukocyte count was 25,500/cu mm with many nucleated red blood cells (RBC) and pronormoblasts. The infant's blood type was 0, RH-positive, and the direct Coombs test was posi¬ tive with anti-C and anit-D eluted from the cells. Phototherapy was begun immedi¬ ately, since parental religious preference precluded the use of blood products in treatment.During the first three hours of life, the total serum bilirubin level rose at the rate of 1 mg/hr. At nine hours, the hemoglobin level was 9.8 gm/100 ml, and the total serum bilirubin level was stable at 8.3 mg/100 ml with a direct fraction of 0.8 mg/100 ml. Physical examination at this time revealed splenomegaly and moderate pallor. A polyethylene catheter was in¬ serted into the umbilical vein to insure ad¬ equate hydration.During the next three days, the infant developed progressive anemia associated with decreased activity and vigor. During the fifth day of life, she was noted to have a small, left-parietal cephalhematoma. The overlying skin was intact. Abdominal dis¬ tension, irritability, and inactivity were present. The liver edge was felt at the um¬ bilicus, and tachycardia and tachypnea were prominent. The hemoglobin level was 2.8 gm/100 ml, and the hematocrit reading was 12%. After obtaining legal consulta¬ tion and court action, 95 ml of freshpacked, type-O, RH-negative blood cells were infused. Since the clinical condition and physical examination indicated ...

MRI features of an infected cephalhaematoma in a neonate

“…Late presentation is characterised by the development cellulitis over the involved area. [7][8][9][10] In the present case, it is not clear whether the infected cephalhaematoma caused the systemic sepsis or was the result of preceding bacteraemia.…”

“…Most cases reviewed by Blom and Vreede 1 were diagnosed late, leading to severe complications including osteomyelitis, sepsis, meningitis and death. Ellis et al 8 suggested that bony radiolucencies on skull X-rays should arouse suspicion of infection. However, Harris and Meeks 11 later reviewed the frequency of these radiolucencies and discovered that they were a common finding and did not necessarily indicate local infection.…”

“…8,[12][13][14] The treatment of associated osteomyelitis may include extensive incision, drainage, and debridement of necrotic bone. 15 This is a complex and potentially high-risk procedures in the neonate.…”

Focal Bacterial Infections

“…Abscesses of the skin and subcutaneous tissue are usually caused by S. aureus and, less frequently, by group A streptococci, GBS [607,608], or gram-negative enteric bacilli [609][610][611][612][613][614][615][616][617]. Community-acquired MRSA organisms are even more likely to produce skin infections with abscess formation.…”

“…Haemophilus species [618][619][620], Gardnerella vaginalis [621], Bacteroides species [622], molluscum contagiosum [623], Drosophila myiasis [624], scabies [625], and Candida [626] are examples of diverse causes of cutaneous abscesses; virtually any bacterial, fungal, or parasitic agent that is normally or transiently on skin may become a pathogen. E. coli, Klebsiella species, P. aeruginosa [605,610,627], N. gonorrhoeae [628], and Bacteroides fragilis [629] have caused wound infections in infants whose scalps were lacerated by forceps, fetal electrodes, or instruments used for obtaining blood from the scalp in utero. An extensive outbreak of systemic disease caused by S. marcescens in an NICU in Puerto Rico included wound infections at the site of intravenous infusions.…”