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A neonate presents with swollen left eye, discharge
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A 5-day-old infant presents to the ED for evaluation of a swollen left eye. The history of the chief complaint began that day, when the patient awoke in the morning with her left eye swollen shut, with some yellowish discharge from the eye. She had no other symptoms and was feeding normally. Her medical history included a 19-year-old mother with good prenatal care, and whose course was unremarkable. The mother had no history of ever having a sexually transmitted infection, including herpes, gonorrhea, chlamydia, HPV, HIV or syphilis. The baby delivered vaginally at term with Apgar scores of 8 and 9 at 1 minute and 5 minutes, respectively. The baby did have some mild physiologic jaundice and was seen at 72 hours of age in the neonatal follow-up clinic with a normal checkup and resolving jaundice.
James H. Brien
Examination in the ED revealed a vigorous, 5-day-old female whose vital signs were normal, and whose only abnormal findings included jaundice and the swollen left eye (Figure 1). Each eye was stained with fluorescein drops for more detailed examination, revealing no discrete lesions; only bilateral scleral icterus and diffuse inflammation of the left eye (Figure 2). The following lab tests were sent: PCR testing for herpes, gonorrhea, chlamydia and adenovirus. A culture and Gram stain of the exudate were sent as well, along with a CBC and blood culture. All of these tests were negative except the culture of the eye, which revealed nontypeable Haemophilus influenzae.
Examination in the ED revealed a vigorous, 5-day-old female whose vital signs were normal, and whose only abnormal findings included jaundice and the swollen left eye (Figure 1). Each eye was stained with fluorescein drops for more detailed examination, revealing no discrete lesions; only bilateral scleral icterus and diffuse inflammation of the left eye (Figure 2)..
Source: Brien JH
What’s Your Diagnosis?
A. H. influenzae conjunctivitis
B. Chlamydial conjunctivitis
C. Escherichia coli conjunctivitis
D. Vitamin A deficiency
The best answer is A: H. influenzae conjunctivitis. By the numbers, H. influenzae (nontypeable) is second only to Chlamydia trachomatis as the most common cause of bacterial conjunctivitis in neonates. But in those with good prenatal care, and no history of STIs, and with a negative chlamydia PCR, H. influenzae rises to the top of the list of bacterial causes of conjunctivitis in neonates. Also, growing it on culture would also seem to make it the most likely in this case.
The baby was treated empirically with cefotaxime and erythromycin in the ED, with gentamicin ophthalmic drops added on the pediatric ward. However, with the negative PCR results mitigating against gonorrhea and chlamydia, and the stained eye exam being normal, only topical gentamicin drops were continued beyond the second day, to complete a 5-day course. The infant went home and was sent to follow-up with her primary, who documented rapid resolution. A polymyxin B-containing drop or ointment could also be used.
The earliest sign of vitamin A deficiency would be retinopathy, resulting in night-blindness, followed by ulceration of the conjunctiva and, ultimately, blindness (Figures 3 and 4).
If chlamydia was the diagnosis, treatment should be with an oral macrolide. Erythromycin at a dose of 50 mg/kg/day in four divided doses for 10 to 14 days has been the standard until the association with hypertrophic pyloric stenosis became known. Many experts now recommend azithromycin, at a dose of 20 mg/kg as a single daily dose for 3 days. Also remember, it is a reportable infection.
Gram-negative bacilli, such as E. coli, may occasionally cause neonatal conjunctivitis, but statistically much less common than nontypeable H. influenzae. However, it is notable that E. coli has surpassed group B strep as the most common cause of neonatal sepsis. This is likely a testament to the effectiveness of the preventive management protocol now widely used.
The neonate seen in Figures 5 and 6 presented with his mother.
Vitamin A deficiency can certainly cause xerophthalmia (severe dryness and thickening of the conjunctiva), which can lead to inflammation that might be confused with infectious conjunctivitis. The earliest sign of vitamin A deficiency would be retinopathy, resulting in night-blindness, followed by ulceration of the conjunctiva and, ultimately, blindness (Figures 3 and 4). Vitamin A deficiency can also have an adverse effect on the immune system, especially with a case of measles. A case of severe vitamin A deficiency is rare in this country, and then usually seen in the setting of malnutrition associated with incredible dietary ignorance or abuse. In either case, this complication of vitamin A deficiency would not be seen in a neonate. To read more about this fascinating case of vitamin A deficiency shown in Figures 3 and 4, look for it in the September 2013 issue of Pediatric Annals, written by my colleague,
The neonate seen in Figures 5 and 6 presented with his mother, seen in Figure 7.
Lastly, if one sees conjunctivitis on the first day or two of life, think of chemical conjunctivitis from the prophylaxis used. Also, for babies presenting at least a few days later, don’t forget to ask about sick contacts, and look at the parents of a neonate with conjunctivitis. The neonate seen in Figures 5 and 6 presented with his mother, seen in Figure 7. They both had adenoviral conjunctivitis, a very common and contagious viral form of this disease that often causes bilateral infections.
Disclosure: Brien reports no relevant financial disclosures.