A report describes a case of a 4.5-month-old female who presented with a 2-day history of watery diarrhea and fever that developed 12 hours before admission. She suffered ten watery stools over the previous 24 hours, during which she became quite unsettled, crying a lot while drinking half her usual amount of liquids. She did not have a history of vomiting.

Her medical history was significant for delivery at term via emergency cesarean section due to severe fetal distress, with a birth weight of 2910 g; and Apgar score of 0-1 at one and five minutes, respectively, after delivery requiring tracheal intubation and transfer into neonatal intensive care unit. She underwent induced coma and active hypothermia for 72 hours. The infant was extubated on the fourth day of life, followed by the reestablishment of enteral nutrition by day 5. She exclusively received formula milk from birth. 

Her day 5 MRI showed signs of severe hypoxic-ischemic encephalopathy. She had irregular follow-ups after discharge and did not receive any vaccines until the current hospitalization episode. Her weight curve was a reason for concern, and her weight two weeks before her current hospital admission was 4390 g.

On the day of presentation, a physical examination demonstrated an alert but irritable and ill-appearing infant with a temperature of 39.9°C, heart rate between 170 and 190 beats/min, a respiratory rate between 40 and 80 breaths/min, blood pressure of 102/55 mmHg, and oxygen saturation by pulse oximetry of 100%. Her weight was 3990 g, indicating she lost 10% of the previously reported weight. Her skin was pale grey, with tenting skin turgor, dry lips, dry buccal mucosa, normal-looking eyes but reduced tears, soft fontanel, and capillary refill time of 3 seconds. Her urine output was decreased. Heart and lung examinations were normal except for tachycardia. Her abdomen was swollen and slightly painful on palpation, and there was no hepatosplenomegaly. 

Her Abdominal and thorax radiographs were normal. She showed no signs of meningeal irritation. The routine stool specimen was positive for rotavirus antigen (Vikia Rota-Adeno, Biomerieux); however, the blood and urine culture results were negative. Serum electrolytes were significant for a sodium concentration of 146 mEq/L and a bicarbonate level of 8 mEq/L. Blood urea nitrogen was 61 mg/dL.

She was initiated intravenous fluid therapy to correct her tachycardia, polypnea, and low blood pH by attempting volume repletion with two subsequent doses of 0.9% sodium chloride at 20 mL/kg over 60 minutes. She received a solution containing dextrose 5% plus electrolytes soon after the second dose of normal saline to attain the slow correction of hypernatremia. Her Diuresis was reestablished within four hours of rehydration therapy. Digestive losses of water and electrolytes were compensated by oral rehydration solution (ORS) at an initial dose of 10 mL/kg and thereafter replaced volume per volume depending on the amount of stool losses. She received Enterol (yeast of Saccharomyces boulardii) as an adjuvant treatment to ORS. Her Metabolic acidosis was difficult to correct during the first 48 hours because of large liquid losses due to diarrhea. Despite the difficulties experienced in restoring the electrolytic balance, the infant displayed an outstanding digestive tolerance throughout the entire hospital stay, which allowed the continuation of enteral nutrition with lactose-free formula milk.

At 24 hours after admission, hyperleukocytosis with neutrophilia and increased C-reactive protein in blood prompted antibiotic treatment with ceftriaxone 100 mg/kg/day; however, it was suspended three days later due to negative bacterial culture results. Her stools were not tested for the presence of Clostridium difficile. She received Adjuvant treatment with gelatin tannate on the third day of hospitalization. Her Metabolic acidosis improved in the following 48 hours, along with a substantial reduction in stool output. She received exclusive feeding by oral route from the fifth day. 

The patient showed favorable progress; however, she received a discharge from the hospital three days later to achieve optimum nutrition and to ensure vaccinations were up to date. Upon discharge from the hospital, her weight was 4.640 kg.

Guzganu IL. Severe diarrhea in a 4-month-old baby girl with acute gastroenteritis: a case report and review of the literature. Case Rep Gastrointest Med. 2012;2012:920375. doi: 10.1155/2012/920375. Epub 2012 Mar 25. PMID: 22606438; PMCID: PMC3350249.