# Neonatal‐Onset Chronic Granulomatous Disease Presenting With Recurrent Culture‐Negative Meningitis: A Case Report and Diagnostic Considerations

## TL;DR

A newborn with a rare immune disorder had recurring meningitis-like symptoms, and a specific test helped diagnose the condition early.

## Contribution

Highlights the importance of DHR testing in diagnosing CGD in infants with recurrent culture-negative meningitis.

## Key findings

- A female infant presented with recurrent febrile illnesses and culture-negative meningitis, later diagnosed with CGD.
- DHR oxidative burst assay confirmed CGD with abnormal stimulation indices.
- Early diagnosis and treatment with amikacin led to clinical recovery.

## Abstract

Chronic granulomatous disease (CGD) is a primary immunodeficiency caused by defective phagocyte oxidative burst and may present in early life with severe or recurrent infections. We report a female infant born at 38 weeks’ gestation (birth weight 2700 g) who developed fever and presumed sepsis at 5 days of life, followed by multiple recurrent hospitalizations for febrile illness with suspected meningitis, diarrhea, dehydration, and failure to thrive. Cerebrospinal fluid (CSF) evaluations across episodes demonstrated pleocytosis with elevated protein and normal‐to‐low glucose, while Gram stain and CSF cultures were repeatedly negative, consistent with recurrent culture‐negative meningitis. Laboratory assessment showed intermittent anemia, thrombocytosis, and episodes of significant neutropenia. Complement and immunoglobulin levels were within reference ranges, and flow cytometry demonstrated preserved T‐ and B‐lymphocyte compartments. A flow cytometric dihydrorhodamine (DHR) oxidative burst assay was markedly abnormal (phorbol 12‐myristate 13‐acetate stimulation index 13%; Escherichia coli stimulation index 22.3%), supporting the diagnosis of CGD. At ~4.5 months of age, a sterile catheter urine culture grew multidrug‐resistant Klebsiella pneumoniae at ≥100,000 CFU/mL with susceptibility limited to aminoglycosides; the patient was treated with amikacin 15 mg/kg/dose intravenously once daily for 10 days, with defervescence within 48 h, clinical recovery, and a repeat urine culture showing no growth. Genetic testing was not performed due to financial and social constraints, and longer‐term outcomes beyond early infancy were unavailable in the record extract. This case underscores that recurrent culture‐negative meningitis in early infancy should prompt evaluation for primary immunodeficiency and that early DHR testing can expedite CGD diagnosis and guide timely preventive management and specialist referral.