A 4-year-old boy is brought by his parents to the volunteer medical center of a large refugee camp in Egypt for evaluation of eye redness. For 10 days the boy has had mild rhinorrhea and cough that are now resolving. He began having mild eye redness 2 days ago with scant, watery discharge. He has not had ocular pain or itching. The patient's 6-year-old brother has similar symptoms. The family fled their home in Sudan due to regional conflict and arrived in the refugee camp approximately 2 months ago. The boy's grandfather and 2 dogs remained at their home. Vital signs are stable. Examination of the chest and abdomen is unremarkable. Examination of the eyes shows several pale follicles and inflammatory changes in the tarsal conjunctivae bilaterally. The conjunctivae appear mildly thickened. Visual acuity is 20/20 bilaterally. Which of the following is the most likely diagnosis for this patient?

Question

A 4-year-old boy is brought by his parents to the volunteer medical center of a large refugee camp in Egypt for evaluation of eye redness.  For 10 days the boy has had mild rhinorrhea and cough that are now resolving.  He began having mild eye redness 2 days ago with scant, watery discharge.  He has not had ocular pain or itching.  The patient's 6-year-old brother has similar symptoms.  The family fled their home in Sudan due to regional conflict and arrived in the refugee camp approximately 2 months ago.  The boy's grandfather and 2 dogs remained at their home.  Vital signs are stable.  Examination of the chest and abdomen is unremarkable.  Examination of the eyes shows several pale follicles and inflammatory changes in the tarsal conjunctivae bilaterally.  The conjunctivae appear mildly thickened.  Visual acuity is 20/20 bilaterally.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

This child's conjunctival injection, tarsal inflammation, and pale follicles are concerning for trachoma. Trachoma is due to Chlamydia trachomatis serotypes A, B, and C and is the leading cause of blindness worldwide. C trachomatis spreads effectively in crowded or unsanitary conditions. The active phase is most common in children and is characterized by follicular conjunctivitis and pannus (neovascularization) formation in the cornea. There is often a concomitant nasopharyngeal infection (eg, rhinorrhea, pharyngitis). Repeated or chronic infection leads to scarring of the eyelids and inversion of the eyelashes (trichiasis). Over time, the lashes rub on the eye and cause ulcerations and blindness (cicatricial trachoma). The diagnosis can be made clinically by examination of the tarsal conjunctivae. C trachomatis may be visible by Giemsa stain examination of conjunctival scrapings. Oral azithromycin is effective against C trachomatis; in general, the entire region (eg, village, refugee camp) should be treated simultaneously. For individuals with trichiasis, eyelid surgery is needed to preserve vision. (Choices A and B) Gonococcal (2-5 days) and chlamydial (5-14 days) conjunctivitis are common causes of conjunctivitis after birth (ophthalmia neonatorum). They are acquired through contact with infected genital secretions. They both present with conjunctival injection, eye discharge, and swollen eyelids. They are rare in older children. (Choice C) Herpes simplex keratitis presents as pain, photophobia, and decreased vision. Vesiculo-ulcerative lesions are commonly present in the corneal epithelium. (Choice D) Tertiary syphilis can manifest as uveitis, causing eye redness, ocular pain, and decreased vision. Tertiary syphilis is extremely rare in children and, when present, should raise suspicion for sexual abuse. (Choice E) Orbital cellulitis refers to infection posterior to the orbital septum. These infections are unilateral and more common in children with paranasal sinus infection. Patients present with an abrupt onset of fever, proptosis, restriction of extraocular movements, and swollen, red eyelids. Educational objective: Trachoma is due to infection with Chlamydia trachomatis serotypes A, B, and C. Acute trachoma presents with follicular conjunctivitis and inflammation. Repeated or chronic infection causes inversion of the eyelashes and scarring of the cornea. References: Trachoma. (http://www.ncbi.nlm.nih.gov/pubmed/25043452) Trachoma: past, present, and future. (http://www.ncbi.nlm.nih.gov/pubmed/27830198)

A 4-Year-Old Boy Is Brought by His Parents to the Volunteer