A six-day-old term boy was admitted with fever, lethargy, poor feeding and irritability – nonspecific but alarming signs of possible neonatal sepsis. Initial examination and laboratory findings (low CRP, modestly elevated leukocytes and monocytes) did not clearly differentiate between bacterial and viral infection. In line with guidelines, broad-spectrum intravenous antibiotics (ampicillin and gentamicin) were started, and a full sepsis work-up was initiated. Lumbar puncture was attempted but unsuccessful, underscoring a common challenge in neonates: the need to decide on antibiotic duration without cerebrospinal fluid (CSF) results.
Given the mother’s recent febrile illness with headache and myalgia, an older sibling with respiratory symptoms, and the infant’s erythematous pharynx, viral infection (particularly enterovirus) was considered. Blood, urine, stool and nasopharyngeal samples were collected. PCR testing of serum and stool using an in-house enterovirus/parechovirus assay detected enterovirus in both specimens, while a broad respiratory PCR panel from the nasopharynx was negative.
Detection of enterovirus in stool alone can represent asymptomatic shedding and does not exclude concomitant bacterial sepsis. In this case, however, viraemia documented by enterovirus-positive serum strongly supported that the virus was the cause of the infant’s systemic illness. Combined with low inflammatory markers, lack of bacterial growth in cultures and clinical improvement (better feeding, weight gain, defervescence), this allowed clinicians to attribute the febrile sepsis-like presentation to enterovirus and safely discontinue empirical antibiotics after a short course.
The subsequent clinical course, specifically recurrence of fever and later onset of seizures with CSF pleocytosis and markedly elevated protein, confirmed central nervous system involvement. Enterovirus was later demonstrated in CSF and typing identified Coxsackievirus B5. Nevertheless, the initial serum PCR result had already been pivotal: it accelerated aetiological clarification at a time when CSF was unobtainable and informed early stewardship decisions.
This case highlights that enterovirus is a frequent but under-recognised cause of neonatal sepsis-like illness and meningoencephalitis, and that serum PCR is a particularly valuable diagnostic tool. Demonstration of viraemia indicates active, clinically relevant infection, supports early differentiation from bacterial sepsis and provides a robust basis for shortening or avoiding prolonged broad-spectrum antibiotic therapy in vulnerable neonates, provided that careful clinical observation and appropriate cultures are in place. Routine inclusion of serum enterovirus PCR in the evaluation of febrile neonates with sepsis-like presentations may therefore improve diagnostic precision and antimicrobial stewardship.
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