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What other pathway should you consider when evaluating a presumed case of conjunctivitis?

Business has been brisk in the Pediatric ED today and you’re getting tired towards the end of your shift. A four-year-old boy with a chief complaint of pink eye has just shown up, and you’re thankful for the break. You dispatch the medical student down the hall to check it out.

A few minutes later the student is back. She reports that the child had been well until about two days ago when he developed redness in his right eye with watery drainage. His mother reports he keeps rubbing it. He has had a low-grade fever but is still active and playful. He has not had any URI symptoms and is not complaining of ear pain. The mother got more worried this morning when she noticed swelling in front of his right ear.

The vital signs are unremarkable and there is no fever at the present time. The student reports that the only abnormalities she found on physical exam were injection of the right eye with “bumpiness” of the lower palpebral conjunctivae and a firm, non-tender preauricular node on the right side. 

You go down the hall to confirm the student’s findings. Sure enough, the child is smiling and active. The right eye is quite infected. It is watery but there is no purulent discharge. You invert the upper lid and there is no foreign body. Pulling down the lower lid there is a small nodule and some prominence of the follicles. The rest of the eye exam is benign. The patient has an area of swelling in the preauricular region on the right that feels like a lymph node. It is minimally tender with no redness or fluctuance.

OK, unilateral pink eye with preauricular adenopathy. You’ve seen this before. The nodule and follicles on the lower palpebral conjunctivae are typical. What history didn’t the student get?

“Does he play with cats or kittens?” you ask the mother. It turns out, the neighbor has a new kitten and all the neighborhood kids have been playing with it.

“Is this cat scratch disease?” asks the student. You explain about Parinaud’s oculoglandular syndrome.

Parinaud’s oculoglandular syndrome is a granulomatous conjunctivitis. It is usually associated with preauricular or submandibular adenopathy on the same side as the affected eye. The vast majority of the time it is due to cat scratch disease although there are other causes, such as tularemia and sporotrichosis, which should be considered if the history or course are not suggestive of cat scratch disease. The cat may scratch the eye but more commonly the disease is acquired by rubbing the eye after contact with the cat. Some patients will have mild fever and systemic symptoms with this but most will not. The disease is benign and self-limited but may resolve faster with antibiotics. The causitive organism is Bartonella henselae. It responds well to erythromycin and doxycycline. IFA and Elisa tests are available to confirm the diagnosis of cat scratch disease but are not necessary if the patient is otherwise healthy with a typical presentation. About 2-17% of patients with cat scratch disease present with Parinaud’s oculoglandular syndrome.

Parinaud’s oculoglandular syndrome is not contagious. Tell the daycare it is fine for the child to attend. He doesn’t need topical eye drops or ointment. The only prevention is to avoid cats. Good luck with that.


Amy Levine, MD, is an associate professor of pediatric emergency medicine at UNC Chapel Hill.

 

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