A 5-day-old female is seen in the ED for evaluation of a red left eye.
The history of the chief complaint began only 6 hours earlier when the parents
noted a yellowish discharge from the left eye, along with mild lid swelling and
erythema a bit beyond the birthmark she had. There was no fever or change in
her activity or appetite, and no other symptoms, such as vomiting, diarrhea,
cough, congestion rash or irritability.
James H. Brien
The neonate’s past medical history included a normal pregnancy with
good prenatal care, labor and delivery, and the mother has no history of
sexually transmitted infections. She received her first hepatitis B
immunization prior to discharge from couplet care. Her family history is fairly
unremarkable; living with her extended family, including several other
children, but no known sick contacts. Animal exposure includes only family
dogs. She has not left home since birth.
Figure 1: There was some dried, yellowish
material between the medial canthus and the bridge of the nose.
Examination revealed normal vital signs and a generally normal-appearing
baby with a normal exam, with the exception of her left eye. Examination of her
eyes included a normal-appearing right eye, but there was some dried, yellowish
material between the medial canthus and the bridge of the nose, with a thin
amount over the bridge of the nose toward the left eye, as shown in Figure 1.
The left eye had mild conjunctival erythema and injection (Figure 2), along
with mild swelling and erythema of the lids and some mucopurulent discharge, as
seen in Figure 3.
Figure 2: The left eye had mild conjunctival
erythema and injection.
Figure 3: Along with mild swelling and
erythema of the lids, there is some mucopurulent discharge.
In the ED, the neonate had a normal complete blood count, and blood
culture is pending. She also had the following lab tests: bacterial cultures;
Gram stain, Chlamydia polymerase chain reaction (PCR); gonococcal PCR,
herpes PCR; adenovirus PCR; and a nasal respiratory virus panel by PCR are
pending. The patient was given a dose of cefotaxime IV and oral azithromycin
before sending to the ward. HINT: All PCRs and Gram stain were negative.
What’s Your Diagnosis?
A. Chlamydial ophthalmia
B. Haemophilus influenzae (nontypable)
C. Herpes conjunctivitis
D. Adenovirus conjunctivitis
Your choice may not be listed, but of these choices, (B) nontypable
Haemophilus influenzae (NTHi) is the most likely and, in fact, that is
what grew from the bacterial culture. As mentioned in the hint, all the rapid
tests by PCRs were negative, and although these can be falsely negative, there
are additional hints against the other choices.
Chlamydial conjunctivitis can occur in a child this young, but typically
is seen a bit later; usually 1 to 2 weeks of age. The other key STI that causes
neonatal conjunctivitis is Neisseria gonorrhoeae. It tends to occur very
early; usually within a couple of days of exposure (birth). Both are more
likely to produce a more severe disease, especially N. gonorrhoeae, but
there’s obviously some overlap.
Additionally, with good prenatal care, these causes are statistically
less likely. The same holds true for herpes simplex virus (HSV), but of course,
half of those babies with neonatal herpes infection have mothers with no
history of genital herpes; the age of presentation for neonatal HSV is about 5
to 14 days, as in the patient presented. However, a properly obtained specimen
should reveal a positive PCR. Also, there may be some cutaneous lesions nearby
Figure 4: There may be some cutaneous
lesions nearby (Figure 4).
Figure 5: Adenovirus is one of the most
common causes of conjunctivitis in older infants and children.
Adenovirus is one of the most common causes of conjunctivitis in older
infants and children (Figure 5), but is statistically rare in neonates.
It’s not that they cannot get it, they just don’t have as much
exposure at this age, and the PCR was negative.
Additionally, other common respiratory viruses are also very uncommon in
neonates, but not unheard of. Sometimes, patients can have multiple pathogens
simultaneously, as shown in Figure 6, which is an infant with
laboratory-verified respiratory syncytial virus rhinitis/bronchiolitis and
As a general rule, if the baby has an inflamed eye within hours of
birth, it is almost always due to chemical irritation from the prophylaxis
used. An exception might be if the mother’s membranes had been ruptured
for several days. Then all the early-onset causes must be considered.
Figure 6: Patients can have multiple
Back to the answer; NTHi is increasingly recognized as a significant
pathogen in neonates, causing everything from early-onset sepsis to
conjunctivitis. Colonization is acquired during birth from maternal vaginal
flora. Its role in acute otitis media has been long recognized. Further
characterization of the role of NTHi as a respiratory tract pathogen is
detailed by Schumacher and colleagues in the February issue of the Pediatric
Infectious Disease Journal.
Whatever the cause turns out to be, one should work quickly to rule out
the more severe possibilities, such as herpes, gonorrhea, chlamydia,
Staphylococcus aureus, Pseudomonas aeruginosa, etc, with a good
history and physical and any supporting lab tests as needed.
Treatment of neonatal conjunctivitis may need to be fairly aggressive
initially until the etiology is known. Then, if it is a common bacterial
conjunctivitis, as in this case, one can use sensitivity data from the culture
to guide therapy. This patient had a beta-lactamase–negative strain of
NTHi that could be treated with several options, both topical and oral.
To read more about conjunctivitis in the pediatric patient, I would
refer you to the supplement in the November 2011 issue of Infectious
Diseases in Children, “Pediatric Conjunctivitis, current perspectives
on treatment to optimize patient care.”
This month marks the end of 23 years of writing this column. If you have
suggestions or constructive criticisms, please let me know. I have made changes
along the way based on your feedback, but we can always make it better. Just
let me know at email@example.com. Also, I hope your spring is off to a
James H. Brien, DO, is a member of the Infectious Diseases in
Children Editorial Board as well as Vice Chair for Education at The
Children’s Hospital at Scott and White and is the Associate Professor of
Pediatrics at Texas A&M University, College of Medicine, Temple, Texas.
email: firstname.lastname@example.org. Disclosure: Dr. Brien reports no relevant financial