CASE ANALYSIS

It has been reported a case of a new born baby girl with acrocyanosis during hospitalizing in NICU
M.Djamil Hospital. Patient was hospitalized with Low birth body weight neonate 1600 gram and
Respiratory distress due to Hialin Membran disease when admitted. After few days hospitalization
and got improvement, patient suddenly got acrocyanosis.

We came across a newborn preterm, born to a G2A1 mother, at 34 weeks gestation, by emergency
lower segment Cesarean section (LSCS) (in view of severe pre‑eclampsia). The baby cried after
birth. The birth weight was 1.36 kg. The APGAR scores at one and five minutes were 8 and 9,
respectively. The mother had received two doses of antenatal steroids, and the antenatal scans
including Doppler’s were normal and had no risk factors for sepsis. The baby after being born was
stable in room air and did not require any form of respiratory support. The baby was
hemodynamically stable and was maintaining normal oxygenation and saturation in room air. The
infant was eumorphic and euglycemic. Trophic feeds were introduced on day one. The baby also
received total parenteral nutrition through a peripherally inserted central line. At 18 hours of life,
the baby was seen to have acrocyanosis in the bilateral upper and lower limbs. The peripheral and
core temperature difference was more than 3ºC. The baby also developed hypotension and
metabolic acidosis.

Peripheral cyanosis, also known as acrocyanosis, refers to the presence of cyanosis in the
extremities and is due to an increased oxygen extraction resulting from sluggish movement of
blood through the capillary circulation. (saccomani) Acrocyanosis is characterized by symmetric
bluish discoloration of hands and feet. (serdaroglu) . Acrocyanosis is often seen in infants as a
consequence of transient hypothermia inducing peripheral vasoconstriction. However, other
causes of cyanosis, such as vasomotor instability, venous obstruction, polycythemia, and low
cardiac output, should also be evaluated. .(saccomani)

For this patient, the possibility of vasomotor instability was considered. Preterm babies are
subjected to many stresses after being born. Out of many complications that a preterm suffers,
vasomotor instability is a significant one, which is observed in few early and late preterms. The
infant usually develops acrocyanosis, temperature instability, hypotension, and sepsis‑like
features. (Mohanty) Vasomotor instability occurs in extreme preterm, but it can occur in the late
preterm population also. Vasomotor instability should be suspected in preterms having the
above‑mentioned features, who are clinically well, but develop signs of hemodynamic instability
such as acrocyanosis, hypotension, and temperature instability. (Mohanty)

Rarely, acrocyanosis in infant can be caused by Raynaud’s phenomenon (RP). Classically,

the initial description of RP involved triphasic color changes in the digits, with blanching (white)
leading to cyanosis (blue) followed by reactive hyperemia (red) [2,3]. RP is manifested via
vasospasm of the small muscular arteries and arterioles of the digits [18]. RP can triggered by
exposure to cold and emotional stress. In response to cold, various vasoconstricting substances
such as catecholamines, endothelin-1, and 5-hydroxytryptamine are released. These chemical
mediators could cause digital artery vasoconstriction and the symptoms of RP. It can be
asymmetric and may last longer. The diagnosis of primary RP in infants is challenging and it can
take weeks to months to confirm the diagnosis. The rarity of its occurrence in infants, the
similarities in clinical presentation between primary RP and benign acrocyanosis of infancy, and
the absence of diagnostic tests confirming the diagnosis of primary RP contribute to delay in the
diagnosing of RP. Clinical clues that should alert the clinician to suspect RP in infancy include the
presence of atypical features such as a prolonged acrocyanosis episode (> 72 hours) and/or a
unilateral acrocyanosis. (Sharathkumar) This patient was not suitable with Raynaud’s
phenomenon. Patient did not had symptom of triphasic color changes in the digits. Acrocyanosis
in patient may not triggered by exposure to cold and emotional stress because patient was in
incubator with temperature was, and condition of patient disease was already improve than before.
Acrocyanosis that happened in this patient got better in 3 days.in contrast with RP which presence
prolonged acrocyanosis episode (> 72 hours) and/or a unilateral acrocyanosis.
Sudden appearance of an episode of cyanosis in a newborn in the hospital nursery who is
expected to be healthy has to do monitor vital signs and carry out biochemical and some
instrumental diagnostic tests. (Dani carlo) The evaluation should systematically assess the infant
for airway, pulmonary, and circulatory causes. The history should include an assessment of the
pregnancy, labor, and newborn risk factors. (Steinhorn)
The oxygen saturation is the percentage of hemoglobin that is chemically combined with
oxygen, which represents the vast majority of oxygen content in the blood. Pulse oximetry
provides excellent non-invasive and continuous assessment of oxygen saturation. Measurement of
arterial blood gas oxygen tension is standard practice, but the pain of an arterial puncture may
produce agitation and changes in ventilation and oxygenation. A venous blood gas may be useful
for the assessment of pH and PaCO2, but should not be used to determine oxygenation. In either
case, the presence of a significant metabolic acidosis may indicate cardiac failure, sepsis, asphyxia,
or metabolic disorders. (Steinhorn) in this patient…..
The cardiac exam should be done include an assessment of the infant’s heart rate,
peripheral pulses, and perfusion. Auscultation of the heart should focus on the second heart sound,
which will be loud and single (or narrowly split) in pulmonary hypertension, as well as
transposition and pulmonary atresia. An electrocardiogram (ECG) is useful for the diagnosis of
cardiac arrhythmias. However, normal newborns have a predominance of right-sided forces, and
moderate right ventricular hypertrophy is a common finding with many types of respiratory and
cardiac disease. Therefore, the EKG is seldom helpful in the evaluation of the infant with
congenital heart disease, and is often completely normal even in infants with serious disease such
as transposition. (Steinhorn) Screening echocardiography of patient was normal. ECG had not
done to the patient.

Early onset sepsis may also be suspected. Acyocyanosis due to vasomotor instability
generally mimics early onset sepsis (EOS) and causes hemodynamic instability. It is generally
unrecognized in such preterms, as they are attributable to sepsis and a majority of them receive
antibiotics and improve on their own. (Mohanty). This patient had done septic screening and blood
cultur examination with result….

Serum electrolytes, Serum, Calcium (Ca), and Magnesium (Mg) were normal as well.

Infantile acrocyanosis is a benign and self-resolving condition, it does not require medical
attention. (Sharathkumar) It resolves in the first week of life. (serdaroglu) Vasomotor instability
usually only treat with fluid, temperature management, and sometimes inotropes are all that are
required. The baby improved over the next 12 hours, the blood pressure normalized, the
acrocyanosis disappeared, and finally the peripheral temperature difference also came down.
(Mohanty). This entity should be kept in mind by the treating neonatologist and one should not be
in a hurry to do too many investigations, which are of little use. But other diagnosis should be
eliminated before we thought of acrocyanosis due to vasomotor instability.
 EVIDENCE BASED MEDICINE

A. Clinical Question
How are psychiatric disorders after corticosteroid therapy in systemic lupus erythematosus?
B. Component of foreground question (PICO)
Population/problem : psychiatric manifestations after corticosteroid therapy in patients
with systemic lupus erythematosus (SLE)
Intervention : Corticosteroids theraphy
Comparator : -
C. Outcome : We prospectively followed for 8 weeks 139 consecutive
episodes in 135 in-patients who had a non–CNS-SLE flare treated with corticosteroids.
Psychiatric events were evaluated once a week using DSM-IV criteria. We then conducted a
post hoc etiological analysis of any newly developed psychiatric events during this follow-up
period. This study suggests that corticosteroid therapy triggers CIPDs and CNS-SLE in
patients with SLE. Delirium may be suggestive of CNS-SLE, while mood disorders may be
more suggestive of CIPDs.
D. Searching Methode
http://e-resources.pnri.go.id/library search engine was used to find eligible article with key
word Corticosteroid therapy, Corticosteroidinduced, psychiatric disorders, Neuropsychiatric
lupus, Systemic lupus erythematosusand found article : New-onset psychiatric disorders after
corticosteroid therapyin systemic lupus erythematosus: an observational case-seriesstudy on
J Neurol (2014) 261:2150–2158. Authors: Katsuji Nishimura, Masako Omori,Eri
Sato,Yasuhiro Katsumata , Takahisa Gono , Yasushi Kawaguchi