TABLE 1173 Differential Diagnosis of Allergic and Infectious Conjunctivitis

In approaching infectious conjunctivitis (Fig 11.7-1), the physician must decide whether the ocular disorder is one manifestation of a systemic illness such as measles or is occurring in relative isolation. Isolated conjunctivitis may be due to various viruses and bacteria, of which herpes simplex and N. gonorrhoeae are particularly severe, or to C. trachomatis, especially in the first 3 months of life.

FIG. 117-1. Approach to the child with an isolated, infectious conjunctivitis. Abbreviations: F/U, follow-up; GC, gonorrhea culture.

Fluorescein staining always should be performed in an effort to identify the dendritic corneal ulcerations characteristic of herpetic disease. If they are identified, treatment is with acyclovir or other antiviral agents under the supervision of an ophthalmologist. Because N. gonorrhoeae is usually acquired during passage through the birth canal, infants under 1 month of age must always be tested for this pathogen with a Gram stain and culture. If gram-negative intracellular diplococci are seen on smear, a single intramuscular injection of ceftriaxone (125 mg) is indicated.1

Infants beyond 1 month of age and older children with an obvious clinical diagnosis of conjunctivitis do not routinely require smears or cultures. In patients under 3

months of age, treatment is instituted with erythromycin (50 mg/kg/day) orally for C. trachomatis (Table 1...1.7-4). Older children require only topical antibiotic instillation into the conjunctival sac. A child who has unusually severe disease or who fails to respond to therapy within 48 h may benefit from a laboratory investigation. Appropriate studies in the infant under 1 month of age would include a Gram stain and bacterial culture and either a scraping or culture for C. trachomatis. Older children require only a Gram stain and bacterial culture. Diagnostic tests for herpes simplex are not usually rewarding in the absence of corneal ulceration; culture for adenoviruses may be helpful in persistent or severe hemorrhagic infections to avoid unnecessary additional testing, but there is no specific treatment. All children with conjunctivitis should be reevaluated within 48 h. Failure to improve warrants further investigation and continued, careful follow-up.

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