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Eye irritation
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Kernicterus
Pyloric stenosis
Sedation
Transaminitis
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This 11-day-old patient who was born at home and presents with mucopurulent discharge from both eyes and periorbital edema most likely has chlamydial conjunctivitis. Oral erythromycin is the treatment of choice; this medication is associated with an increased risk of infantile hypertrophic pyloric stenosis. Chlamydia trachomatis is the most common bacterial cause of neonatal conjunctivitis. Infection of the conjunctiva tends to be more serious in neonates due to reduced tear secretion, decreased immune function, decreased lysozyme activity, and a lack of immunoglobulin IgA in the tears. Clinically, chlamydial conjunctivitis tends to present 5 to 14 days after birth with hyperemia, scant mucoid discharge, eyelid swelling, and chemosis. Diagnosis can be secured by polymerase chain reaction (PCR) testing performed on a conjunctival scraping. Options for prophylaxis against neonatal conjunctivitis include topical silver nitrate, erythromycin (for gonococcal conjunctivitis), and tetracycline. Treatment for chlamydial conjunctivitis is typically with systemic erythromycin or azithromycin. A rare side effect of erythromycin is infantile hypertrophic pyloric stenosis, a condition in which hypertrophy of the pylorus can lead to obstruction of the gastric outlet. Zikic et al. reviewed the treatment of neonatal chlamydial conjunctivitis. The authors found that erythromycin given at 50 mg/kg per day for 14 days had a clinical cure rate of 96%. The authors recommend the use of erythromycin or azithromycin to treat chlamydial conjunctivitis. Incorrect Answers: Answer 1: Eye irritation is a side effect of topical erythromycin therapy. Topical erythromycin alone is not an effective therapy for chlamydial conjunctivitis as topical therapy does not eradicate nasopharyngeal infection. In contrast, topical erythromycin is used for prophylaxis against gonococcal conjunctivitis in the neonate. Answer 2: Kernicterus is a rare side effect of ceftriaxone, a cephalosporin antibiotic that can be used to treat gonococcal conjunctivitis. Because ceftriaxone displaces bilirubin from albumin binding sites, it should be avoided in neonates with hyperbilirubinemia. Gonococcal conjunctivitis usually presents in younger patients (3 to 5 days) with mucopurulent discharge, chemosis, and severe lid edema. Answer 4: Sedation is a side effect of cetirizine and other antihistamines that can be used in the treatment of allergic conjunctivitis. Allergic conjunctivitis is usually part of a larger systemic atopic response (e.g., allergic rhinitis) and is associated with redness, chemosis, itching, and lacrimation. Mucoid discharge would not be expected. Answer 5: Transaminitis is a side effect of ceftazidime, another cephalosporin that can be used to treat gonococcal conjunctivitis. Ceftazidime should be used in patients with clinically significant hyperbilirubinemia, as treatment with ceftriaxone in these patients can lead to bilirubin encephalopathy. Bullet Summary: Oral erythromycin is the treatment of choice for neonatal chlamydial conjunctivitis; infantile hypertrophic pyloric stenosis is a serious potential adverse effect of this medication.
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