A 1-month-old male infant is brought to our NICU with poor feeding and failure to thrive. He is the product of a second-degree consanguineous marriage, born of a gravida 3, para 2 woman. Family history includes an older sibling’s death on day 7 due to intracranial bleeding.

The neonate is born vaginally with a birthweight of 3,800 g. He develops respiratory distress and excessive irritability on day 1. He has received humidified high-flow nasal cannula oxygen for 5 days. Investigation shows a C-reactive protein of 1.65 mg/dL (16.5 mg/L). Blood culture and cerebrospinal fluid (CSF) cultures are sterile. Magnetic resonance imaging (MRI) of the brain shows a normal study. He is discharged from the hospital after receiving 7 days of intravenous (IV) antibiotics.

The infant is seen with poor feeding, lethargy, and weight loss of 21% of birthweight. A physical examination shows depressed sensorium, responsiveness to painful stimuli, white eye...

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