Haemolacria: a case of pseudomembranous conjunctivitis in a neonate
- Michelle Marie Boffa and
- Amaris Spiteri
- Department of Adolescent and Child Health, Mater Dei Hospital, Msida, Malta
- Correspondence to Dr Michelle Marie Boffa; michelle-marie.boffa@gov.mt
Abstract
We report an unusual case of an 11-day-old neonate presenting with haemolacria on a background of sticky conjunctival discharge. This was secondary to Chlamydia pseudomembranous conjunctivitis which responded well to systemic erythromycin. Early appropriate treatment is important to prevent progression of the ophthalmic infection, which could lead to blindness, and to prevent other manifestations of neonatal chlamydial infection, particularly pneumonia, which could be fatal. Management also includes treating the mother and educating about sexually transmitted infections.
Background
Although with the advent of the UK National Chlamydia Screening Programme for women under 25 years of age chlamydial infections are less common, they must still be considered in neonates presenting with severe forms of conjunctivitis, as in our case. This is more so in patients in endemic countries, or where such screening is unavailable, as in our country (Malta) or in patients falling out of the screening criteria.
Case presentation
A previously healthy 11-day-old neonate was brought to the paediatric accident and emergency department with sudden onset of bilateral haemolacria.
According to his parents, the neonate had been experiencing sticky discharge from both eyes for the previous 24 hours, for which he was started on moxifloxacin eye drops by their family doctor with no improvement. The child was at home when he started crying inconsolably without provocation. On inspection of the child, the mother noticed fresh blood coming profusely out of both eyes.
The child was not febrile with no changes in feeding pattern and behaviour. Further history taking was unremarkable apart from an uncomplicated inguinal hernia repair in the perinatal period. On examination, the eyelids were bilaterally oedematous with yellowish crusting and ongoing haemolacria. A subsequent review by the ophthalmic team confirmed severe conjunctivitis with pseudomembrane formation (pseudomembranous conjunctivitis), the pseudomembrane itself being responsible for the bleeding. Funduscopy was unremarkable, with normal fixation and extraocular eye movements. The pseudomembrane was removed and eyelid cleansing performed. Topical antibiotics were modified empirically to fusidic acid 1% viscous eye drops, given three times per day for 2 weeks, pending eye swab culture results. A general systemic examination revealed no other abnormalities.
Mum denied having had any genitourinary symptoms suggestive of infection. During the examination, the father’s demeanour was inappropriately angry raising the question of the possibility of non-accidental injury. This led to further probing into the family dynamics where no sufficient evidence of non-accidental injury was found and the father’s response to the situation was deemed to be purely reactive.
Investigations
Eye swab PCR was positive for Chlamydia trachomatis. Eye swab cultures were negative for bacteria; however, the neonate was already on topical antibiotics at the time of culture, which would have interfered with results. No abnormalities were found on blood investigations.
Differential diagnosis
The main differentials were severe neonatal conjunctivitis, an adverse reaction to topical treatment, non-accidental injury and a bleeding diathesis. Severe neonatal conjunctivitis with pseudomembrane formation was the most likely diagnosis in view of the 24-hour history of sticky eyes in a neonate. An adverse reaction to topical treatment was also considered as conjunctival haemorrhage secondary to moxifloxacin has been reported; however, this is rare. Non-accidental injury with trauma to the eye, possibly on a background of friable conjunctivae was also considered but ruled out from history and examination, as was a bleeding diathesis, which was unlikely due to normal investigations.
Treatment
Having already debrided the pseudomembrane and cleansed the eyelids, the pseudomembranous Chlamydia conjunctivitis was subsequently treated with oral erythromycin, given a 12.5 mg/kg/dose for a total of 14 days four times a day.
Following consultation with our local infectious diseases team, the neonate was also given a single dose of ceftriaxone (administered at 12.5 mg/kg intramuscularly) despite not having tested positive for gonorrhoea, in view of the risk of it being present simultaneously with Chlamydia in the mother. The parents were subsequently referred to the genitourinary clinic for a full sexually transmitted infection work-up, including testing for Chlamydia and were started on empiric antibiotics in view of the strong clinical suspicion. When the sexually transmitted infection was confirmed, antibiotics were continued as a treatment course.
Outcome and Follow-up
The neonate was reviewed after completing 2 weeks of oral erythromycin treatment. He had fully recovered from the conjunctivitis and remained otherwise well in himself.
Two weeks later, the patient presented to the accident and emergency department with tachypnea; however, this was due to nasal congestion on the background of an upper respiratory tract infection with no signs of chlamydial pneumonia.
The parents were also followed up by the genitourinary clinic team, during and after the antibiotic course.
Discussion
Haemolacria, which refers to bloody tears, is a rare condition which is most often caused by infection, laceration or inflammation at the level of the conjunctiva, eyelids or nasolacrimal system.1 In our case, it was due to pseudomembranous conjunctivitis.
Conjunctivitis is an inflammatory condition whereby conjunctival hyperaemia results in oedema and chemosis. This in turn results in an exudate that when mixed with tears and mucin forms the typical sticky discharge.2 Pseudomembranous conjunctivitis occurs when due to the high fibrin content, the inflammatory exudate conglomerates over the conjunctival surface to form a superficial film called a pseudomembrane.
This can be removed easily without bleeding unlike in true membranous conjunctivitis which involves the conjunctival epithelium and so leaves a raw bleeding surface when removed.2
Apart from non-infective causes including burns, Steven-Johnson syndrome and ocular cicatricial pemphigoid, pseudomembranous conjunctivitis often occurs secondary to infections2 (table 1).
Infectious causes of pseudomembranous conjunctivitis
| Bacterial pathogens | Viral pathogens |
| Beta-haemolytic streptococci | Adenovirus |
| Neisseria gonorrhoeae | Herpes simplex |
| Neisseria meningitides | |
| Corynebacterium diphtheria | |
| Chlamydia trachomatis |
In our case, the causative agent was C. trachomatis. This is the most common cause of ophthalmia neonatorum (conjunctivitis occurring in the first 4 weeks of life) in the developed world.3 4 Neisseria gonorrhoeae is another common cause of ophthalmia neonatorum.4 C. trachomatis is mainly transmitted to neonates following exposure to an infected mother’s genital flora during vaginal delivery.5 Conjunctivitis is its most common neonatal manifestation, with an incubation period of 5–14 days, although rarely it could present earlier in cases of premature rupture of membranes.6 Early adequate treatment is important due to the risk of progression to corneal scarring and blindness and of the risk of pneumonia, which occurs in 10%–20% of neonates with chlamydial infection.2 Pneumonitis, rhinitis and otitis are other possible systemic complications.7 Neonatal Chlamydia infection can be prevented with an adequate antenatal screening programme.
Systemic treatment is always necessary, as although topical treatment may improve conjunctival symptoms, it would not eliminate nasopharyngeal chlamydial carriage and thus not eliminate the risk of progression to pneumonia. First-line treatment is erythromycin and azithromycin is a suitable second-line agent. Erythromycin is given over 14 days at a dose of 12.5 mg/kg/dose, four times per day.7 8 Management also includes screening the neonate for other vertically transmitted, sexually transmitted infections and parental screening and adequate treatment.
Despite C. trachomatis causing ophthalmia neonatorium being relatively common, especially in developing countries, haemolacria per se is less so. Although conjunctivitis is known to cause haemolacria on occasion,9 to our knowledge there are no reported cases in the literature of pseudomembranous Chlamydia conjunctivitis causing haemolacria at an age as young as that of our patient. A similar presentation was reported in a 4-month-old infant, however, infective pathology was not confirmed in this case and it was thus deemed to be idiopathic.1
Haemolacria may alarm patients and their carers, but it is usually benign, self-limiting and often unilateral, although the course depends on the underlying aetiology.1 The first documentation of bloody tears dates back to 1581, when Dodonaeus described haemolacria in a 16-year-old pre-menstrual girl.10 This was attributed to vicarious menstruation, and originally it was thought that anantomically, the bleeding could only arise from the lacrimal gland.11
Eventually multiple ophthalmic sources of bleeding were recognised leading to cases with direct clinical causes but also to idiopathic ones when no obvious cause was uncovered.11 12 Of the cases with identifiable aetiology, apart from purely local ophthalmic abnormalities at the level of the conjunctiva, eyelids or nasolacrimal system, systemic disease was attributed to some. These included epistaxis with retrograde flow, vicarious menstruation, hyperthyroidism, drugs and malignancy.13 14 Malingering has also been implicated and in cases where the nature of the red liquid is uncertain, it should be examined under light microscopy to look for blood components.13
Management of haemolacria is multidisciplinary, due to the wide range of possible underlying aetiologies. Psychological input should be considered, not only for cases of malingering, as the experience of haemolacria might be rather traumatic for patients and their families, especially in cultures where superstition plays a prominent role.13 In our case, multidisciplinary management involved dealing with the underlying infection in the child with input from paediatric infectious disease specialists and opthalmolgists, and addressing the infection in the parent by liaising with the genitourinary clinic. Although psychological input was considered, it was not deemed necessary initially as the family understood and subsequently coped well with the matter. However, follow-up ensured that we remained open to the possibility of a delayed psychological referral should the need arise.
Patient’s perspective
At first I thought he was crying because the detergent my dad had just sprayed a couple of metres away had somehow made it into his eyes, but when I rushed to console him I saw the blood gushing out. It was horrible! I thought he would go blind—I mean who would have thought that blood could actually pour out of a baby’s eyes, it’s unheard of!
Learning points
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In neonates presenting with haemolacria, it is important to rule out severe conjunctivitis secondary to sexually transmitted infections in the mother.
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Proper treatment including systemic antibiotics early on is essential in Chalmydia conjunctivitis to prevent local progression to trachoma and scarring with blindness, and to prevent progression of the infection to Chlamydia pneumonia.
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Adequate referral of the parents to be investigated for other sexually transmitted infections is part of the management of such cases.
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Parental chlamydial infection must be adequately treated and education about sexually transmitted infections provided.
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A full social history and clinical assessment should be undertaken to rule out non-accidental injury in haemolacria.
Footnotes
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Contributors MMB was the initial doctor assessing the patient in the emergency department and AS was the paediatric emergency department consultant on-site on the day, who subsequently reviewed the patient and helped in managing, including follow-up after the acute period. The report was initially drafted by MMB and subsequently reviewed and with further appropriate input by AS, to compile the final case report. Thus, both authors (MMB and AS) contributed to the clinical care and management of this patient, together with the compiling of this report.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Patient consent for publication Parental/guardian consent obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.
References
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