Extern Conference

1. Extern Conference Ophthalmia Neonatorum

2. A 17-day-old female term newborn Case presentation • CC:purulent discharge from Rt eye for 3 days • PI: • 7 d PTA, Rt eye showed whitish-grey watery discharge and tear but no eyelid swelling was detected. • 3 d PTA, Rt eyelids were red and swelled with occasional bloody-purulent discharge. • She was treated by topical ATB and eye irrigation with sterile water but these symptoms did not improve. • She had no fever, no drowsiness, no URI symptoms. She was breast-fed well.

3. History • Birth history:G1P0A0, GA 38 wks, NL, Apgar 10,10 BW 3,090 g, length 50 cm, HC 33 cm • There was no complication after delivery. • History of pregnancy: • serology : neg • no maternal history of STD • amniotic membrane ruptured 7 hr before delivery • mother had no fever or vaginal discharge. • Family history: no genetic or contagious disease • No history of drug allergy • Vaccine: BCG, HBV1

4. Physical examination BW 3,700 g (P50-75), length 54 cm (P75-90). HC 35 cm (P50) V/S: T 36.8°C, P 168/min, R 40/min GA: active and non-toxic child, not irritable, not pale, no jx, no dyspnea, no signs of dehydration HEENT: pharynx and tonsils are not injected Rt eye: red and mildly swollen eyelid, marked conjunctival injection with purulent and bloody discharge, clear cornea, EOM and VA cannot be evaluated Lt eye : normal

5. Physical examination CVS: normal S1, S2, no murmur RS: normal breath sound, no adventitious sound Abd: soft, not tender, no hepatosplenomegaly NS: normal movement, Brudzinski’s sign negative

6. Problem list 1. Unilateral purulent discharge (Rt eye) 2. Mild eyelid swelling with marked conjunctival injection (Rt eye)

7. Differential Diagnosis • Ophthalmia neonatorum (neonatal conjunctivitis) • Neonatal dacryocystitis • Periorbital cellulitis

8. Differential Diagnosis Ophthalmia neonatorum: in this patient • Pros • Age of onset • Clinical symptoms • Most common cause in newborn • Cons • No history of maternal infection or vaginal discharge -Schachter, J, Grossman, M. Chlamydia. In: Infectious Diseases of the Fetus and Newborn, 5th ed, Remington, JS, Klein, JO (Eds), WB Saunders, Philadelphia 2001. p.769. -de Toledo AR, Chandler JW: Conjunctivitis of the newborn. Infect Dis Clin North Am1992 Dec; 6:807-13

9. Differential Diagnosis Neonatal Dacryocystitis • onset 2-4 wk • Tenderness & swelling in medial canthal region • Epiphora most prominent • ±purulent D/C from puncta, cellulitis, conjunctivitis, In this patient • Epiphora was not eminent • No tenderness & swelling in medial canthal region Lang, Gerhard K., Ophthalmology: a short textbook, 2000 Georg Thieme Verlag, Germany

10. Differential Diagnosis Periorbital cellulitis • Local spread (preceded with URI) • Acute eyelid erythema and edema • Pain, epiphora • ± fever, conjunctivitis, , leukocytosis In this patient • Mild eyelid edema • No Hx of URI, hordeolum, bug bite, trauma • Discharge more prominent than swelling Malinow I, Powell KR: Periorbital cellulitis. Pediatr Ann 1993 Apr; 22:241-6

11. Differential Diagnosis

12. Approaching pediatric conjunctivitis History • Maternal/paternal infection during pregnancy esp. STD • Onset, severity, characters of discharge • Associated symptoms, preceding illness • Possible causes of illness (trauma, bug bites)

13. Approaching pediatric conjunctivitis Physical examination • eyelid eversion: hyperemia, follicles, papillae, membranes • Characters and amount of discharge (purulent, mucoid, watery, bloody) • Detailed eye exam if possible (EOM, VA, pupillary reaction, proptosis) • Preauricular lymphadenopathy • Systemic manifestation (fever, pneumonia, sinusitis, meningitis, arthritis)

14. Ophthalmia neonatorum

15. Ophthalmia neonatorum • Neonatal conjunctivitis – during the first mo • Aseptic – chemical: silver nitrate • Septic – bacteria, chlamydia, virus • Septic neonatal conjunctivitis • Neisseria gonorrhoeae (GC) – most serious • Chlamydia trachomatis – most common • Non-gonococcal, non-chlamydial • Acquire during passing through the birth canal

16. Incidence • One of the most common eye disease in neonate • Incidence ranging from 1.6-12.0% Weiss AH. Conjunctivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediatric infectious disease, 2003, pp 486-89.

17. Clinical presentation • Common findings: erythema and edema of the eyelids conjunctival injection chemosis watery to purulent eye discharge • More specific findings for different causative agents

18. Clinical presentation Adapted from: Weiss AH. Conjunctivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediatric infectious disease, 2003, pp 486-89.

19. Investigation • Gram stain • conjunctival exudate Cited from: Weiss AH. Conjunctivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediatric infectious disease, 2003, pp 486-89. • When to perform? • Look more severe • Persist than 2-3 days or progress • First appear after the first day of life

20. Histologic study Ophthalmia neonatorum Gram stain • Chemical conjunctivitis • Bacterial conjunctivitis • Chlamydial conjunctivitis • neutrophils, lymphocytes • neutrophils, bacteria • neutrophils, lymphocytes, plasma cells

21. Provisional diagnosis

22. Gonococcal infection

23. Investigation for Chlamydial infection • Conjunctival scraping for chlamydia • Giemsa stains from lower conjunctiva • intracytoplasmic inclusion bodies • Do not collect from ocular discharge alone • Culture • Non-culture method • Direct immunofluorescent antibody assay • Nucleic acid amplification tests (PCR)

24. Chlamydial inclusion body

25. Management 1. If there are systemic symptoms, admit the patient for specific treatments and further investigation 2. Laboratory investigations include discharge G/S, cultures 3. IV or IM third-generation cephalosporin should be given before laboratory results 4. Topical ATB is not necessary 5. Consult ophthalmologist

26. Specific treatment 1. Gonorrhea conjunctivitis (non-disseminated) • Admit and separate patient from other babies • Ceftriaxone 25-50 mg/kg/day IM single dose not to exceed 125 mg. • Irrigated with NSS frequently until discharges disappear • Treat parents 2. Chlamydia conjunctivitis • Erythromycin oral 50 mg/kg/day qid for 14 days • 0.5% erythromycin ointment tid/qid for 3 wks (unnecessary but may be adjunctive) • Irrigated with NSS frequently until discharge disappear • Treat parents Red Book: 2006 Report ofthe Committee on Infectious Diseases.27th ed.

27. Prophylaxis • Baby that born from Gonorrhea-infected mother • Ceftriaxone 25-50 mg/kg/day (max 125 mg) IM single dose stat or aqueous pen-G 100,000 U IV single dose • The American Academy of Pediatrics and the U.S. Centers for Disease Control(CDC) • 1% silver nitrate solution • 0.5% erythromycin ointment • 1% tetracycline ointment Red Book: 2006 Report ofthe Committee on Infectious Diseases.27th ed.

28. Progression 16/4/50 (Day 1) • Admit (consult ophthalmologist: r/o orbital cellulitis) • Observe clinical signs: sepsis • RE: mild lid swelling, not tensed, erythema; conjunctival injection with chemosis; purulent bloody discharge wih pseudomembrane, full EOM

29. Progression 16/4/50 (cont.) • Investigation • G/S of discharge: numerous PMN, no organism • Giemsa staining of conjunctival scraping: pending • Discharge culture for GC, bacteria, Chlamydia trachomatis: pending • CBC: Hb 12.7 g/dL Hct 38.1% WBC 11640/mm3 N30.5% L 49.7% M16.2% E3.4% B0.2% plt 343000/mm3

30. Progression 16/4/50 (cont.) • Imp: Ophthalmia neonatorum, suspected C. trachomatis conjunctivitis • Start ATB covering GC and Chlamydia • Ceftriaxone 50 mg/kg/day iv over 30 min, single dose • Erythromycin Syr 50 mg/kg/day for 14 days • Topical ATB : erythromycin ed. (Tobrex ed. instead) • Evaluate and treat mother  OPD Gynae

31. Progression 18/4/50 (Day 3) • Giemsa stain (16/4/50): not appropriate specimen • Repeated conjunctival scaping for Giemsa • Zymar (Gatifloxacin) ed to RE q 2 hr (12.5 MKdose) 17/4/50 (Day 2) S: active child, afebrile O: RE: eyelid swelling, soft; conjunctival injection with chemosis; purulent bloody discharge; normal cornea A: not worse P: continue treatment

32. Progression • 19/4/50 (Day 4) • Afebrile • RE: eyelid not swelling, conjunctiva-mildly injected, small amount of discharge, clear cornea • Plan F/U OPD eye 1 week, with Giemsa stain result

33. Take home message • NB with conjunctivitis are at risk of systemic infection • Hx of mother (ANC, STD, perinatal Hx) and child • Complete PE • Treat for GC if it cannot be ruled out and admit if there is evidence of systemic infection. • Presumptive treatment is based on the clinical picture, G/S and Giemsa • Systemic ATB, not just ATB eye drop, is recommended. (Chlamydia, GC, HSV) • Evaluate and treat the parents.

34. References • American Academy of Pediatrics.Red Book: 2006 Report ofthe Committee on Infectious Diseases.27th ed. Elk Grove Village,IL: American Academy of Pediatrics;2006:401–411 • de Toledo AR, Chandler JW: Conjunctivitis of the newborn. Infect Dis Clin North Am1992 Dec; 6:807-13 • Lang, Gerhard K., Ophthalmology: a short textbook, 2000 Georg Thieme Verlag, Germany • Malinow I, Powell KR: Periorbital cellulitis. Pediatr Ann 1993 Apr; 22:241-6 • Weiss AH. Conjunctivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediatric infectious disease, 2003, pp 486-89. • Schachter, J, Grossman, M. Chlamydia. In: Infectious Diseases of the Fetus and Newborn, 5th ed, Remington, JS, Klein, JO (Eds), WB Saunders, Philadelphia 2001. p.769

35. Thank you for your attention