To Patch or Not to Patch, That is the Question

Patient Presentation
An 18-month-old female came to clinic after a few hours of crying and refusing to open her right eye. The symptoms began after she was fighting with her sister over a toy. The sister reports that the toy hit the toddler in her eye.
The past medical history reveals that she is otherwise well.
The pertinent physical exam shows her right eye to be generally pink and watering and she refused to open it for examination. After a topical anesthetic and fluorescein was applied, the Wood’s lamp evaluation found a 3 mm corneal abrasion at 3 o’clock lateral to the pupil. The rest of the ophthalmologic examination was normal including eversion of the eyelid.
The diagnosis of corneal abrasion was made. She was treated with Erythromycin opthalmic ointment and covered with a pressure patch to prevent further rubbing of her eye, although she removed it later that evening. One day later the child had no pain and repeat examination showed complete healing of the abrasion.

Discussion
Corneal abrasions are a loss of corneal epithelium that exposes the corneal nerves. It is caused by physical or chemical trauma and can often be missed. It is the most common corneal eye injury. Symptoms include pain, tearing, redness, photophobia, foreign body sensation and blepharospasm. The diagnosis is made with history, eye examination and fluorescein staining of the eye with Wood’s lamp or slit lamp visualization. The fluorescein dye stains areas of removed epithelium and fluoresces a greenish-white color under blue light. It is important to remember to examine the underside of the eyelid to rule out a retained foreign body.
Most corneal abrasions heal in 24-48 hours but corneal scarring, ulcerations or infections of the cornea and iris do occur. If the eye still has an abrasion after 48 hours, has increased pain, pain with no obvious defect, or a clouded cornea, an ophthalmologic evaluation is needed.

Other common causes of a painful eye related to the eye itself include:

  • Corneal abrasion
  • Conjunctivitis
  • Foreign body
  • Chelazion
  • Blepharitis
  • Keratitis – bacterial, Herpes simplex
  • Uveitis/iritis
  • Intraocular infection
  • Glaucoma (acute)

Learning Point
Treatment for corneal abrasion includes:

  • Patching of the eye – Theoretically patching may decrease friction of the eyelid on the cornea, improving comfort and accelerating healing. The theoretical disadvantages include decreased oxygen delivery to the cornea which is needed for healing, increased moisture which may result in increased infection, and if the patch is applied inappropriately it may cause corneal abrasions. Patching is not recommended in contact lens wearers because of the risk of incubating infectious organisms.

    Although patching is recommended by many standard textbooks, there are several newer studies which find that the benefit of patching is questionable and may itself cause other problems.

    • A meta-analysis found no improvement in healing rate or pain and 48% complained of the patch causing pain itself (see Flynn, 1998 in To Learn More below).
    • One randomized controlled trial found no improvement in healing rate or pain. (see Le Sage, 2001 in To Learn More below).
    • Another randomized controlled trial found no improvement in healing rate but more problems with difficulty walking (see Michael, 2002 in To Learn More below)

    The child in this case was patched because the physicians felt that she would continue to rub her eye and risk further damage.

  • Topical analgesics – Theoretically these may decrease the pain but they can be toxic to keratocytes and may delay healing. They should be used in the evaluation process only. Ice may help to relieve some pain caused by eyelid swelling.
  • Topical antibiotics – The goal is to prevent infection in the abraded areas. Ointment also helps to lubricate the eye better than drops but can make the vision blurry. Bacitracin, Polymyxin/bacitracin, Erythromycin, and Ciprofloxacin are often used. People who wear contact lenses should have coverage for Pseudomonas.
  • Mydriatics – They may relieve ciliary muscle spasm if present. If they are used, they should be used with caution as they may mask another cause of a painful eye.
  • Follow-up at 24-48 hours is recommended to determine healing.

Questions for Further Discussion
1. Besides corneal abrasion, what are other causes of crying that are often hidden?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Flynn CA, D’Amico F, Smith G. Should we patch corneal abrasions? A meta-analysis.
J Fam Pract. 1998 Oct;47(4):264-70. Available from the Internet at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9789511

Le Sage N, Verreault R, Rochette L.
Efficacy of eye patching for traumatic corneal abrasions: a controlled clinical trial.
Ann Emerg Med. 2001 Aug;38(2):129-34. Available from the Internet at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11468606

Michael JG, Hug D, Dowd MD.
Management of corneal abrasion in children: a randomized clinical trial.
Ann Emerg Med. 2002 Jul;40(1):67-72. Available from the Internet at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12085075

Verma, A. Corneal Abrasion. eMedicine.
Available from the Internet at http://www.emedicine.com/oph/topic247.htm (rev. 10/19/04, cited 1/26/05).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
February 21, 2005

When Should Antiretroviral Therapy be Started for Non-Occupational Exposure to HIV?

Patient Presentation
A 21-year-old female calls the outpatient clinic stating she had vaginal sexual intercourse 2 days ago. She and her male partner were using condoms and spermicidal foam. The condom broke after ejaculation, and she had already begun emergency contraception. She has just found out that her partner is HIV positive (human immunodeficiency virus) and wants to know what she should do about the risk.
Her past medical history reveals her to be otherwise well and she had her regular health maintenance examination 2 months ago which included a normal pelvic examination, sexually transmitted infection screening and cervical cancer screening. Her immunizations including Hepatitis B are current. She is told to make an appointment for that day.
The diagnosis of non-occupational exposure to HIV is confirmed.
She is counseled about her risk for becoming HIV positive as well as other sexually transmitted infections and pregnancy. She is also counseled about the potential side effects of antiretroviral therapy.
The laboratory evaluation included HIV antibody, complete blood count, liver function testing, blood urea nitrogen, creatinine, pregnancy testing, Hepatitis C serology, and sexually transmitted infection testing for Gonococcus, Chlamydia, and Syphilis. She is begun on nonoccupational postexposure prophylaxis and will followup in 4 weeks.

Discussion
Acquired Immunodeficiency Syndrome / Human Immunodeficiency Virus (AIDS/HIV) is a retrovirus known for viremia that is persistent, nervous system infection, weak host immune responses, and especially for its latency. HIV binds to CD4 lymphocytes and monocytes and becomes internalized, replicating by reverse transcriptase. The viral DNA becomes incorporated into the host DNA allowing further replication.
After its latency, HIV infection causes profound immune suppression with the disease appearing to be almost uniformly lethal. Progression from HIV infection to AIDS occurs at a median of 11 years after infection. Until recently, persons with AIDS could expect to live 1-2 years, but with the introduction of new medication, medication combinations and prophylaxis against opportunistic pathogens, death rates from AIDS have begun to decline significantly.

The Centers for Disease Control (CDC) released a new guideline in January 2005 for the treatment of non-occupational exposure to HIV, referred to as nPEP or nonoccupational postexposure prophylaxis. Previously only occupational exposures were considered for treatment with post-exposure prophylaxis referred to as PEP (see To Learn More below).
Nonoccupational exposure is any ???”direct mucosal, percutaneous, or intravenous contact with potentially infectious body fluid that occurs outside perinatal or occupational settings. Potentially infectious body fluids are blood, semen, vaginal secretions, rectal secretions, breast milk or other body fluid that is contaiminated with visible blood.” (see To Learn More below)

Evaluation of a person seeking care for nonoccupational exposure to HIV should include:

  • Determining the HIV status of the person seeking care as many people do not know if they have already been exposed and are already infected.
  • Determining timing and frequency of exposure – nPEP is less likely to be effective if initiated > 72 hours after HIV exposure. After this time, the likelihood of benefit may not outweigh the risks in taking highly active antiretorviral therapy (HAART). nPEP should only be used for infrequent exposures.
  • Determining HIV status of the source person – If the source is HIV positive, additional history to determine antiretorviral therapy use and most recent viral load may provide help in determine choice of nPEP medications. If the source status is unknown, but from a group with a high prevalence of HIV infection (e.g. homosexual or bisexual man, injection drug user or commercial sex worker), the risk for transmission might be increased. If the status is unknown and the source is available, testing should be done on the source person, and possiblly begin nPEP until the source’s HIV status is determined.
  • Determining transmission risk – the highest risks are for blood transfusions, needle sharing by injection drug users, receptive anal intercourse and percutaneous needle stick injuries.
    Exposure Route                 Rates are per 10,000 exposures
                                    to an infected source
    Blood transfusion                       9000
    Needle sharing infection drug use         67
    Receptive anal intercourse                50
    Percutaneous  needlestick                 30
    Receptive penile-vaginal intercourse      10
    Insertive anal intercourse                 6.5
    Insertive penile-vaginal intercourse       5
    Receptive oral intercourse                 1
    Insertive oral intercourse                 0.5
    
  • Evaluate for sexually transmitted infections, hepatitis and emergency contraception
  • Follow-up includes:
    • Testing for HIV antibodies at baseline, 4-6 weeks, 3 months, and 6 months after exposure. Also testing for sexually transmitted diseases including Hepatitis B and C and pregnancy should be offered.
    • Patient should be instructed about the signs and symptoms associated with acute HIV infection, especially fever and rash, and told to report them.
    • If nPEP is used, monitoring of liver, renal and hematological function as indicated by the exact medications used is recommended.
    • Patients should be instructed to avoid possible transmission to others including the practice of “safe sex,” to avoid shared drug injection equipment, and not to donate tissues and blood.
    • Clinicians should assess the source person’s access to medical care and help to obtain care if necessary.
    • Confidentiality should be strictly maintained and reporting of new HIV infections to health departments and other sources as dictated by local law.

Learning Point
The most effective means of preventing HIV is preventing exposure. The guidelines should be reviewed and are briefly described below and in Table 8.
For persons seeking care < 72 hours after nonoccupational exposure to a source with known HIV infection, a 28-day course of nPEP is recommened using highly active antiretorviral therapy (HAART) beginning as soon as possible.

For persons seeking care < 72 hours after nonoccupational exposure to a source with unknown HIV status when such exposure represents a substantial risk for transmission if the source were HIV infection, no recommendations are made for using nPEP. This needs to be evaluated on a case by case basis.

For persons seeking care > 72 hours after nonoccupational exposure, or with exposure histories that represent no substantial risk of transmission, nPEP is not recommended.

For persons seeking care > 72 hours after nonoccupational exposure with a substantial risk of infection, nPEP may be considered if the determined potential benefit outweighs the risks for transmission and adverse events of HAART.

HAART regimens can be found by consulting the CDC guidelines. Overall, no specific antiretorviral medicaltion or combinations of medications are optimal for use as nPEP. HAART decreases but does not eliminate the transmission risk of HIV even if begun within 72 hours.


Figure 10. Algorithm for Evaluation and Possible Treatment of NonOccupational Exposure to HIV.

Questions for Further Discussion
1. If nPEP is begun, what laboratory testing is recommended at intervals?
2. How do the guidelines change if the patient is a child or is pregnant?
3. What are the criteria for defining HIV and AIDS?
4. What types of HIV testing are available?
5. What are the risks of HAART?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: HIV and AIDS and Contraception.

Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States. MMWR.
Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm (rev. 1/25/2005, cited 1/25/2005).

Dubin J. HIV Infection and AIDS. eMedicine.
Available from the Internet at http://emedicine.com/emerg/topic253.htm (rev. 12/14/2004, cited 1/25/2005).

Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR.
Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm (rev. 6/29/2001, cited 1/25/2005).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
February 14, 2005

What Else Looks Like Scabies?

Patient Presentation
An 11 month-old male came to clinic with a 1 week history of an itchy red rash. The rash appeared under the child’s arms. It spread to the trunk, neck, arms, hands, legs and feet. He seems to be more bothered at night. The family has tried Calamine lotion, Benadryl®, and hydrocortisone with some relief.
He has been otherwise well and has no recent sick contacts. His social history reveals that he lives at home, does not attend daycare, but does go to weekly playgroups. He has been playing outside on a blanket or in the grass.
The past medical history shows a healthy infant with one ear infection in the past.
His review of systems reveals no fever, upper respiratory infection symptoms, new soaps/lotions/detergents, or applied lawn chemicals.
The pertinent physical exam shows a well appearing infant with normal growth and development. His skin examination shows 1-2 mm red papules with excoriation especially in his axilla, neck, face, arms and hands. His trunk and legs are also less involved. Additionally there are also whitish threadlike lines seen especially around his fingers. In the axilla, there are 2-3 mm red lesions that are slightly nodular. None of the skin is wheapy or cellulitic in appearance.
With the clinical history of pruritis, and evidence of burrows, a diagnosis of scabies was made. The patient was treated with permethrin and parents were instructed on environmental control measures. They were also told that the itching of the scabies may last days to weeks after treatment. The parents felt that the Benadryl did help the itching and would continue to use it for symptomatic relief.

Discussion
Scabies results from a mite infection (Sarcoptis scabiei). The female burrows into the skin of the host and tunnels ~2 mm each day laying 2-3 eggs at a time. Fecal pellets are also left behind. Larvae hatch after 3-4 days, reach maturity in 14-17 days, mate, burrow and continue the cycle. Death occurs in 25-30 days.The mite can live 2-3 days outside the human body.

Transmission usually occurs by direct contact or by sharing contaminated linens or clothing. Sexual activity can cause transmission. Scabies often occurs within families. Spread can occur with fomites, but this is less likely. Transmission is unrelated to personal hygiene and infestation occurs in all races and social classes worldwide. Children under 15 years have the highest prevelance.

Patients usually come to attention because of pruritus that is often severe and worse at night. Lesions are small, erythematous papules with obvious excoriation. Burrows are grey/white, threadlike, serpiginous and vary in length. The burrows are often disrupted because of scratching. Papules, wheals, and vesicles can also be seem. Nodules are often seen in covered parts of the body such as the axilla, groin, and genitalia and are a granulomatous response to dead mite antigens and feces. The nodules can persist for weeks to months after effective treatment.
Lesions are commonly found on the sides and webbing of the fingers and toes, flexor surfaces of wrists, extensor surfaces of elbows and kness, axilla, periumbilical areas, waist, and genitalia and buttocks. The scalp and back are generally spared. Children however, are more prone to developing diffuse infections often involving the face and scalp. Secondary infection is common.
Scraping from a non-excoriated papula or burrow may allow visualization of a mite, eggs, or feces under a microscope.

Treatment is usually 100% effective if all environmental control measures are applied along with medication use. All family members and close contact should have treatment at the same time to prevent repeated infections. Topical medication should be massaged thoroughly into the skin over the entire body and generally removed by washing after several hours. A single application should be effective, but often 2 treatments 1 week apart are being recommended.

    Permethrin (Elimite®) is a topical agent and is generally considered the most effective. It has decreased absorption than Lindane and therefore less toxicity. Common side effects are mild burning, stinging, rash and redness. Permethrin is more expensive than Lindane.

    Lindane (Kwell®) is another topical agent. It is more neurotoxic and therefore should be left on the skin of babies under 1 year of age for shorter time periods. Pregnant women should not use lindane, nor should persons with seizure disorders

    Crotamiton (Eurax®) is a topical agent that is associatd with frequent treatment failures.

    Ivermectin (Stromectol®) is an oral medication given as a single dose followed by a second dose ~1-2 week later. Cure rate is 70% after the first dose and 95% after the second dose. Scabies treatment is an off-label use of this medication.

Antihistamines are used to treat the pruritis. Treatment of secondary infections with appropriate antibiotics is also important.

Environmental control measures include washing all clothing, bedding and linens in the household in hot water and heating in a drying. Other effective methods include dry cleaning or removing the item from body contact for at least 72 hours. Items that have already been cleaned do not require additional measures.


Figure 8 – Picture of Scabies Mite(Sarcoptis scabiei)from the CDC Laboratory Identification of Parasites of Public Health Concern


Figure 9 – Hand with rash caused by scabies from the CDC Laboratory Identification of Parasites of Public Health Concern

Learning Point

Undiagnosed scabies can last for years – hence the term “seven year itch.” Suspect scabies when multiple family members are involved, there is a crescendo in intensity of the problem over 2-3 weeks, or if the pruritis intensifies at night.
The differential diagnosis may include:

  • Atopic dermatitis / Eczema
  • Contact dermatitis
  • Drug reaction
  • Impetigo
  • Pitaryiasis Rosea
  • Seborrheic dermatitis
  • Pediculosis
  • Urticaria/ Papular urticaria

Questions for Further Discussion
1. How potentially effective are other possible treatments such as sulfur petrolatum?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Scabies.

American Academy of Pediatrics. Scabies, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;547-549.

Gunn VL, Nechyba C. The Harriet Lane Handbook. 16th. Edit. Mosby Publications: St. Louis. 2002:726,735-6,801-2.

Sciammarella,J. Scabies. eMedicine. Available from the Internet at: http://www.emedicine.com/EMERG/topic517.htm (rev. 12/17/04, cited 1/13/05).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
February 7, 2005