Management of Newborn with Fever, Tachycardia, Rhinovirus, and Elevated LFTs

Diagnostic Considerations

The American Academy of Pediatrics recommends that a lumbar puncture should be performed in febrile infants under 28 days, despite the presence of rhinovirus, to rule out bacterial meningitis 1, 2
A Glasgow Coma Score of less than 13 is a contraindication to lumbar puncture, as it may indicate increased intracranial pressure 3, 1
Focal neurological signs, such as asymmetric movements or abnormal posturing, require imaging before lumbar puncture 3
The presence of rhinovirus does not exclude bacterial meningitis, and approximately 20% of febrile infants under 90 days have enterovirus, with roughly 50% of enterovirus-positive infants having CSF pleocytosis 6

Inflammatory markers, such as CRP and procalcitonin, help risk-stratify for bacterial infection 2
Blood culture status should be confirmed before any antibiotics are administered 5, 2
A platelet count of less than 50 × 10⁹/L may be a contraindication to lumbar puncture, although this may be acceptable with hematology consultation 3

A CT scan is not routinely indicated before lumbar puncture unless specific contraindications are present, such as a Glasgow Coma Score of less than 13 or new-onset seizures 7, 3
Routine CT delays diagnosis and is not supported by guidelines for stable infants 3

The combination of tachycardia, fever, and elevated LFTs warrants cardiac evaluation, as viral myocarditis can present with tachycardia out of proportion to fever 4
Rhinovirus is a known cause of viral myocarditis in neonates 4
An echocardiogram will assess ventricular function, pericardial effusion, and valve function 2

The American Academy of Pediatrics recommends initiating ampicillin and gentamicin (or ampicillin and cefotaxime) immediately after lumbar puncture if the infant appears ill or has abnormal laboratory findings 5, 4
Standard dosing: Ampicillin covers Group B Streptococcus and Listeria; aminoglycoside or third-generation cephalosporin covers gram-negative organisms 5

Neonates under 28 days require hospitalization pending culture results, regardless of initial CSF results 4
Repeat CSF analysis in 24-48 hours if initial CSF is normal but clinical suspicion remains high, as 5-10% of HSV encephalitis cases have normal initial CSF with negative PCR 7
Monitor cardiac function closely if echo shows abnormalities, with serial troponins, BNP, and repeat echocardiography may be needed 2