Bulging fontanelle in febrile infants as a predictor of bacterial meningitis

Case series of infants presenting to the emergency department with fever, bulging anterior fontanelle and COVID-19 infection

We present a three patient case series of infants who presented to the pediatric emergency department with fever, bulging anterior fontanelle (BAF), and an omicron variant COVID-19 infection. All patients had a benign course, none developed meningitis, and all had symptom resolution after two days. Considerations for neuroimaging and lumbar puncture are discussed. This case series adds to the previously published case reports of infants with COVID-19, fever and BAF and further describes a variant in the presenting symptomology of COVID-19 infection in infants under 12 months. Acute and primary care providers who treat infants should consider COVID-19 testing in patients who are well appearing, with fever and BAF.

An Infant With COVID-19 Presenting With a Bulging Fontanel: A Case Report and Literature Review

A bulging fontanel is a sign of elevated intracranial pressure, which can be caused by diseases with intracranial fluid retention or swelling of the cerebral parenchyma. We experienced a case of an infant with a typical course of mild coronavirus disease 2019 (COVID-19) but with a bulging fontanel as a finding at presentation. The patient, a three-month-old boy with no underlying conditions, presented to the emergency clinic with fever, vomiting, and loss of appetite. Due to the absence of crying and the bulging fontanel, he was referred to our hospital with suspected bacterial meningitis. The diameter of the anterior fontanel was 2.5 cm, as measured by the Popich and Smith method. He showed no signs of consciousness impairment and appeared to be as active as usual. Computed tomography revealed a bulging fontanel. Cerebrospinal fluid examination showed no elevated cell counts, and cultures were negative. Accordingly, bacterial meningitis was ruled out. The fever resolved on the day after admission, and the patient was discharged on the third day after admission in good general condition. When an infant diagnosed with COVID-19 presents with a bulging fontanel, it is important to be aware of its low specificity and excessive antibiotic treatment should be reconsidered.