Transcript Fracture shaft of Femur

Extern Conference
Ophthalmia Neonatorum
Case presentation
A 17-day-old female term newborn
• 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.
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
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
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
Problem list
1. Unilateral purulent discharge (Rt eye)
2. Mild eyelid swelling with
marked conjunctival injection (Rt eye)
Differential Diagnosis
• Ophthalmia neonatorum (neonatal
conjunctivitis)
• Neonatal dacryocystitis
• Periorbital cellulitis
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
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,
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
Differential Diagnosis
Causes
Clinical
symptoms
Associated
findings
Neonatal
conjunctivitis
Maternal
infection
Discharge,
conjunctivitis
Maternal STD
Neonatal
dacryocystitis
Obstruction of Epiphora,
lacrimal
tenderness at
system
epicanthal
region
Nasal diseases
Periorbital
cellulitis
Local spread
URI
Marked eyelid
edema
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)
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)
Ophthalmia neonatorum
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
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.
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
Clinical presentation
Silver
nitrate
GC
Chlamydia
Herpes
Onset
Day 1
Day 3-5
Day 5-14
Day 6-14
Character
Transient, Hyperacute Acute, varying in
disappear , purulent
severity
in 2-4 days
Corneal epith
defects
Affected eye
Bilat
Bilat
Uni or bilat
Uni or bilat
Corneal
involvement
No
Edema,
ulcer,
perforation
No
(eyelid scarring,
pannus)
Geographic
ulcers
Extraocular
No
Maybe
Maybe (pharyngeal Vesicles on the
colonization,
skin or lid
pneumonitis, otitis) margin, others
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.
Investigation
• When to perform?
• Look more severe
• Persist than 2-3 days or progress
• First appear after the first day of life
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.
Histologic study
Ophthalmia neonatorum
Gram stain
 Chemical conjunctivitis
 neutrophils, lymphocytes
 Bacterial conjunctivitis
 neutrophils, bacteria
 Chlamydial conjunctivitis
 neutrophils, lymphocytes,
plasma cells
• Gram stain
Gonococcal
infection
• Chocolate agar
or Thayer-Martin
Chlamydial
infection
• Giemsa stain
• Culture
Provisional
diagnosis
Other
bacterial
infection
Herpetic
infection
• Gram stain
• Blood agar
• Tzank smear
• Culture
Gonococcal infection
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)
Chlamydial inclusion body
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
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 of the Committee on Infectious Diseases. 27th ed.
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 of the Committee on Infectious Diseases. 27th ed.
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
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
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
Progression
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
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)
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
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.
References
1.
American Academy of Pediatrics. Red Book: 2006 Report of the Committee on
Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of
Pediatrics; 2006:401–411
2.
de Toledo AR, Chandler JW: Conjunctivitis of the newborn. Infect Dis Clin North
Am1992 Dec; 6:807-13
3.
Lang, Gerhard K., Ophthalmology: a short textbook, 2000 Georg Thieme Verlag,
Germany
4.
Malinow I, Powell KR: Periorbital cellulitis. Pediatr Ann 1993 Apr; 22:241-6
5.
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.
6.
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
Thank you for your attention