P3.271: Extended-Spectrum Beta-Lactamase Escherichia coli-Infected Cephalohematoma in an Infant

Introduction: Neonatal cephalohematomas (CHs) are subperiosteal hemorrhages caused by birth trauma and generally resolve spontaneously. In rare instances, they can become infected and present diagnostic challenges due to non-specific symptoms. We report a case of a CH infected with extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli in a three-week-old infant.

Case Description: A 21-day-old, full-term male presented to the emergency department with fever (38.2°C), intractable fussiness, and progressive swelling of a left parietal CH. The infant was born via non-instrumented vaginal delivery without complications. Prior to this presentation, the CH was evaluated twice by ultrasound, showing a stable, mildly complex fluid collection. Physical examination revealed tenderness over a full and tense CH without obvious overlying skin changes (Figure 1). Significant laboratory findings included bandemia, neutropenia, anemia, thrombocytosis, and elevated inflammatory markers. Ampicillin, ceftazidime, and acyclovir were initiated at meningitic dosing. Cerebrospinal fluid studies were non-diagnostic. Initial blood cultures grew S. epidermidis and S. salivarius, which were contaminants. Ultrasound of the CH revealed a large heterogenous collection with multiple thin septations and mixed anechoic and echogenic spaces, consistent with hematoma. A brain MRI revealed a complex, septated, heterogenous CH with gradates signal of evolving blood products, thick peripheral and septal contrast enhancement with suggested restricted peripheral diffusion, and a small amount of subgaleal edema noted along the periphery (Figure 2). Neurosurgery performed fine-needle aspiration with fluid cultures growing ESBL-E. coli. Genomic sequencing classified the pathogen as a global extraintestinal pathogenic E. coli. The patient’s antimicrobials were changed to meropenem, and he underwent an incision and drainage. Given concern for possible osteomyelitis on follow-up brain MRI, the patient received a 6-week course of meropenem leading to gradual clinical improvement. He was discharged from the hospital in good clinical status.

Discussion: Infected CHs are exceedingly rare and often present without specific symptoms. While CHs typically self-resolve, persistent swelling or signs of infection warrant further investigation, including fine-needle aspiration. Imaging can support diagnosis but may not reliably distinguish infection from resolving hematomas. E. coli is the most common pathogen in infected CHs, but ESBL strains are rare, with only one prior case published prior to this report. Possible routes of infection include inoculation during maternal delivery, colonization with subsequent infection, and healthcare associated infection. Although there are no treatment guidelines, evidence supports 2-3 weeks of antibiotics for uncomplicated cases and 4-6 weeks for cases with serious complications, such as osteomyelitis.

Conclusion: Diagnosing infected CHs in neonates is challenging due to non-specific clinical signs and imaging limitations. Fluid aspiration for microbiologic evaluation is essential when infection is suspected. This case underscores the need to consider infected CHs in neonates with fever and signs of sepsis with persistent subperiosteal fluid collections, emphasizing the importance of early diagnosis and tailored antimicrobial therapy.