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Conjunctival Hyperemia or Vasodilation and Central Corneal Ulcer in a Neonate

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An 11-day-old girl presented with a worsening corneal opacity of the right eye. The patient had received a diagnosis of conjunctivitis at 6 days of life but failed to respond to treatment with topical erythromycin ophthalmic ointment, 0.5%. The baby was an otherwise healthy girl born at full term. Her perinatal history was significant only for a positive maternal test for group B Streptococcus agalactiae, which was treated prior to delivery.

Results of the initial examination were significant for conjunctival hyperemia or vasodilation of the right eye, with a 3 × 4-mm central corneal ulcer. Results of B-scan ultrasonography showed no posterior chamber involvement. Corneal cultures for bacteria, fungi, and herpes simplex virus were obtained. Owing to concern for systemic involvement of group B S agalactiae, herpes simplex virus, and other infectious causes, the patient was admitted to the children’s hospital for a full sepsis workup. Treatment with topical polymyxin B sulfate-trimethoprim and intravenous ampicillin, cefepime hydrochloride, and acyclovir sodium was initiated. Results of spinal ultrasonography demonstrated spinal cord tethering at L4, preventing lumbar puncture and collection of cerebrospinal fluid for culture.

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Fungal keratitis caused by Fusarium falciforme

B. Perform corneal biopsy

Infectious keratitis is a significant cause of ocular morbidity worldwide.13 In pediatric populations, ocular trauma is the most common predisposing factor to microbial keratitis.2,3 Neonates are a unique population for corneal infections because they do not present in a similar manner as older children and adults; a corneal defect is often the first symptom described by the parents, followed by discharge and tearing.1 Prior studies postulate that lower concentrations of immunoglobulin A and lysozyme in neonates increase their susceptibility to corneal infections.4 Keratitis typically responds to topical antibiotics or systemic antivirals; however, the development of a hypopyon and the lack of improvement after potent broad-spectrum antibiotics and antivirals should lead to a revised differential diagnosis to include fungal pathogens.

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Article Information

Corresponding Author: Kara M. Cavuoto, MD, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33131 (kcavuoto@med.miami.edu).

Published Online: March 1, 2018. doi:10.1001/jamaophthalmol.2017.5159

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank the family of the patient for granting permission to publish this information.

References
1.
Chaurasia  S, Ramappa  M, Ashar  J, Sharma  S.  Neonatal infectious keratitis.  Cornea. 2014;33(7):673-676.PubMedGoogle ScholarCrossref
2.
Aruljyothi  L, Radhakrishnan  N, Prajna  VN, Lalitha  P.  Clinical and microbiological study of paediatric infectious keratitis in South India: a 3-year study (2011-2013).  Br J Ophthalmol. 2016;100(12):1719-1723.PubMedGoogle ScholarCrossref
3.
Song  X, Xu  L, Sun  S, Zhao  J, Xie  L.  Pediatric microbial keratitis: a tertiary hospital study.  Eur J Ophthalmol. 2012;22(2):136-141.PubMedGoogle ScholarCrossref
4.
Etches  PC, Leahy  F, Harris  D, Baum  JD.  Lysozyme in the tears of newborn babies.  Arch Dis Child. 1979;54(3):218-221.PubMedGoogle ScholarCrossref
5.
Das  S, Sharma  S, Mahapatra  S, Sahu  SK.  Fusarium keratitis at a tertiary eye care centre in India.  Int Ophthalmol. 2015;35(3):387-393.PubMedGoogle ScholarCrossref
6.
Lakhundi  S, Siddiqui  R, Khan  NA.  Pathogenesis of microbial keratitis.  Microb Pathog. 2017;104:97-109.PubMedGoogle ScholarCrossref
7.
Rosa  RH  Jr, Miller  D, Alfonso  EC.  The changing spectrum of fungal keratitis in south Florida.  Ophthalmology. 1994;101(6):1005-1013. PubMedGoogle ScholarCrossref
8.
Thomas  PA.  Fungal infections of the cornea.  Eye (Lond). 2003;17(8):852-862.PubMedGoogle ScholarCrossref
9.
Thomas  PA.  Current perspectives on ophthalmic mycoses.  Clin Microbiol Rev. 2003;16(4):730-797.PubMedGoogle ScholarCrossref
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