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Case Reports Indian Pediatrics 2000;37: 1368-1370 |
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Pseudo-Gonococcal Ophthalmia Neonatorum |
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We report a case of neonatal conjunctivitis misdiagnosed and treated as gonococcal ophthalmia neonatorum based on a Gram stain of the pus discharge showing intra-cellular Gram negative diplococci. Culture and biochemical studies confirmed growth of Moraxella catarrhalis (M. catarrhalis), previously known as Branhamella catarrhalis (B. catarrhalis)(1), which was resistant to penicillin (producing beta-lactamase). This misdiagnosis has obvious social, psychologi-cal and medical implications. This is probably the first case report of neonatal conjunctivitis caused by M. catarrhalis resistant to peni-cillin from India.
A 4-day-old male infant was brought with purulent discharge from both eyes and matting of the eyelids from second day of life. There was no history of fever, cough, and nasal or ear discharge. He was the fourth child of nonconsanguineous parents, born normally at 38 weeks gestation in a local hospital following an uneventful, supervised and protected antenatal period. There was no prior history of recurrent abortions or stillbirths. There were no perinatal risk factors for neonatal sepsis. Mother gave no history of vaginal discharge or ulceration, urethritis, or fever during labor. Parents denied any extra-marital sex. He had no birth asphyxia; birth weight was 2800 g. He was exclusively breastfed. There was no history of instillation of eye drops or massage of eyes after birth. On examination, the infant was alert, active, feeding well at the breast, weight was 2700 g, length 48 cm and head circumference 32.6 cm. Anterior fontanelle was open and flat. Pulse rate was 116/min and respiratory rate was 34/min. He had matting of eyelids with purulent crusts. Conjunctival congestion and chemosis were present. Corneae were lustrous and clear. Moro, rooting and sucking reflexes were normally elicited. Skin and rest of the systemic examination were normal. The smear from pus revealed presence of Gram-negative diplococci and pus cells. The infant was diagnosed to have gonococcal ophthal-mia neonatorum and he was started on parenteral crystalline penicillin in six hourly doses of 50,000 units/kg/dose. Penicillin eye drops (5 lakh units per 5 ml) were also instilled regularly once every 15 minutes into both eyes. The parents were referred to the Infectious Diseases Clinic dealing with sexually transmitted diseases for counselling about nature of the disease and need for further investigations. Maternal vaginal swab smear did not reveal any gonococci, tricho-monas, or candida. After 36 hours, the culture report confirmed growth of M. catarrhalis. The bacterium was resistant to penicillin and susceptible to erythromycin, cotrimoxazole, chloramphenicol and tetracycline. Parenteral crystalline penicillin and penicillin eye drops were then discontinued; oral erythromycin and chloramphenicol eye drops were begun with which there was rapid improvement. The parents were re-assured and advised to bring their son for follow-up after completing the antibiotic course.
Ophthalmia neonatorum is a form of conjunctivitis occurring in infants less than 4 weeks of age. Gonococcal ophthalmia neo-natorum is a medical emergency necessitating prompt hospitalization, isolation and paren-teral therapy with benzyl penicillin or ceftriaxone. Untreated it can result in rapid corneal ulceration, perforation, blindness and death(2). As shown in this case, Neisseria gonorr-hoeae can be misidentified if only Gram staining of the smear is employed. A six year survey of 302 cases of all types of ophthalmia neonatorum showed that some of the 46 gonococcal cases were so designated without being confirmed by culture and biochemical methods(3). Spartk et al. in 1979(4) initially reported M. catarrhalis as causing neonatal conjuncti-vitis while having similar morphology to Neisseria gonorrhoeae on the Gram stained smear. The inflammation due to M. catarrhalis can vary in severity from a mild conjunctivitis to a severe purulent ophthalmia as seen in our case(4). Initially, the few isolated cases of M. catarrhalis conjunctivitis were caused by beta-lactamase negative strains(4,5). The emergence of penicillin resistant organisms was described in 1984(6). Though it is a known commensal of the upper respiratory tract(1), it is a potential pathogen capable of causing otitis media(7), bronchopulmonary infections in patients with chronic lung disease(6), meningitis(8), as well as septicemia with purpura fulmi- nans in children with acute lymphoblastic leukemia(9). M. catarrhalis is easily grown on simple media like blood agar without hemolysis. The colonies are greyish white and friable. It does not cause fermentation of glucose unlike gonococci, is deoxyribonuclease positive, reduces nitrate to nitrite and may be missed on selective media used for isolating gonococci like the Thayer Martin medium and the New York City (NYC) medium(10). Awareness in India of this possible misdiagnosis with its consequent repercus-sions was first created by Qureshi(1). Clini-cians need to be also mindful of the fact that M. catarrhalis may be resistant to penicillin and institute appropriate antibiotic therapy based on culture and susceptibility reports. Contributors: ACP initiated therapy and drafted the paper. SV participated in patient care and data collection. MSM isolated and identified M. catarr-halis. PDM guided the overall management and revised the draft. Funding:
None.
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