A 3-day-old girl is brought to the emergency department due to a day of copious, purulent eye drainage. She was born vaginally to a 31-year-old woman, gravida 3 para 3. The family declined routine prophylactic medications, including vitamin K, erythromycin ointment, and hepatitis B vaccination, for the newborn. The patient was discharged with her parents at 24 hours of life. She has been breastfeeding exclusively and voiding and stooling normally. Temperature is 36.8 C (98.2 F). Examination shows bilateral eyelid edema, conjunctival injection, and purulent discharge. The anterior fontanel is open, soft, and flat. The nares are patent, and the oral mucosa is clear without lesions or thrush. Auscultation reveals clear lungs bilaterally and no murmurs. The abdomen is soft, nontender, and nondistended, and the external genitalia appear normal with no discharge. Which of the following is the most likely diagnosis?

Question

A 3-day-old girl is brought to the emergency department due to a day of copious, purulent eye drainage.  She was born vaginally to a 31-year-old woman, gravida 3 para 3.  The family declined routine prophylactic medications, including vitamin K, erythromycin ointment, and hepatitis B vaccination, for the newborn.  The patient was discharged with her parents at 24 hours of life.  She has been breastfeeding exclusively and voiding and stooling normally.  Temperature is 36.8 C (98.2 F).  Examination shows bilateral eyelid edema, conjunctival injection, and purulent discharge.  The anterior fontanel is open, soft, and flat.  The nares are patent, and the oral mucosa is clear without lesions or thrush.  Auscultation reveals clear lungs bilaterally and no murmurs.  The abdomen is soft, nontender, and nondistended, and the external genitalia appear normal with no discharge.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d701_0d73_bc81_9dbf45a20922_MD0003_00 This patient's severe, bilateral, purulent conjunctivitis in the first few days of life is most likely due to Neisseria gonorrhoeae (gonococcal conjunctivitis). Neonates acquire this gram-negative diplococcus through contact with infected maternal genital secretions during delivery. Therefore, all pregnant women who are age <25 or who have risk factors (eg, history of sexually transmitted infection, new sexual partner) should be screened and treated during pregnancy. Infected newborns classically develop eyelid edema, copious and purulent exudate, conjunctival injection, and chemosis (conjunctival edema) at age 2-5 days. Gonococcal conjunctivitis is the most severe form of neonatal conjunctivitis and can progress to corneal ulceration, scarring, and blindness if untreated. Treatment is a single intramuscular dose of a third-generation cephalosporin (eg, cefotaxime). Gonococcal conjunctivitis can be prevented by topical application of ophthalmic erythromycin shortly after delivery. Because urogenital gonorrhea is often asymptomatic, babies can acquire infection from mothers with no apparent history of it. Therefore, prophylaxis is recommended for all newborns and is mandatory in most parts of the United States. Prophylactic erythromycin ointment does not prevent Chlamydia trachomatis conjunctivitis. (Choice A) Chemical conjunctivitis usually occurs within 24 hours of birth and is most common in neonates prescribed silver nitrate. This medication is effective as gonococcal conjunctivitis prophylaxis but is not used in the United States because of the risk of chemical conjunctivitis. Symptoms are mild, resolve in a day, and do not include purulent discharge. (Choice B) C trachomatis can cause neonatal conjunctivitis but typically 5-14 days after birth. Compared with gonococcal conjunctivitis, chlamydial conjunctivitis typically causes milder chemosis and eyelid swelling as well as watery, rather than purulent, discharge. (Choice C) Nasolacrimal duct obstruction (dacryostenosis) presents with chronic, often unilateral, tearing in infants. Eyelid swelling, conjunctival injection, and copious discharge are not seen. Symptoms usually resolve with gentle massage of the nasolacrimal sac. dacryostenosis (Choice E) Neonatal herpes simplex virus infection of the eye presents in the second or third week of life with vesicular or ulcerative lesions. Purulent discharge in the first week of life is not typical. (Choice F) Staphylococcus aureus is a common cause of bacterial conjunctivitis in adults. It is less common in children and extremely rare in neonates. Educational objective: Gonococcal conjunctivitis presents in the first 2-5 days of life with eyelid swelling, copious and purulent eye drainage, and conjunctival injection, causing blindness if untreated. Prevention is achieved by the application of a topical erythromycin ointment soon after birth. References: Treatment and prevention of ophthalmia neonatorum. (http://www.ncbi.nlm.nih.gov/pubmed/24235191)

A 3-Day-Old Girl Is Brought to the Emergency Department Due