What is the management for a 3-year-old with bilateral conjunctivitis and cough?

Management of a 3-Year-Old with Bilateral Conjunctivitis and Cough

This clinical presentation is most consistent with adenoviral pharyngoconjunctival fever (PCF), which requires supportive care only, with strict hygiene measures to prevent transmission, and close monitoring for corneal involvement. 1

Immediate Assessment for Red Flags

Before proceeding with supportive management, you must rule out vision-threatening and life-threatening conditions:

• Examine the cornea with fluorescein staining to detect early corneal involvement, which is mandatory in any case of conjunctivitis with discharge 1
• Look for purulent discharge that rapidly reaccumulates after cleaning, which would indicate possible gonococcal conjunctivitis requiring immediate systemic antibiotics 1
• Check for eyelid vesicles or rash suggesting herpes simplex virus, which can progress to keratitis, corneal scarring, and perforation 2, 1
• Assess for severe pain, which warrants immediate ophthalmology referral 3

Diagnosis: Adenoviral Pharyngoconjunctival Fever

The combination of bilateral conjunctivitis with cough strongly suggests adenoviral PCF, which presents with the diagnostic triad of fever, pharyngitis, and bilateral conjunctivitis 1:

• Bilateral conjunctivitis (though may start unilaterally before progressing) with watery to serofibrinous discharge 1
• Upper respiratory symptoms including cough and pharyngitis, often with tonsillar exudates 1
• Follicular reaction of the inferior tarsal conjunctiva with bulbar conjunctival injection 2
• Preauricular or periauricular lymph node enlargement may be present 1
• Self-limited course with improvement within 5-14 days 2, 1

Treatment Protocol

Supportive Care (Primary Management)

• Artificial tears for symptomatic relief 4
• Cold compresses to reduce discomfort 4
• Topical antihistamine eye drops for additional symptom control 4
• No antibiotics indicated as this is a viral infection that does not benefit from antibacterial therapy 5, 4

Infection Control Measures

• Strict hand hygiene is essential to prevent transmission to other household members 4
• Keep child out of daycare/school until symptoms improve to prevent spread 3
• Avoid sharing towels, pillows, or other personal items 4

Critical Monitoring Requirements

Monitor for progression to epidemic keratoconjunctivitis (EKC), which can cause subepithelial corneal infiltrates, corneal scarring, and long-term visual sequelae 1:

• Follow-up in 3-4 days to assess for improvement 3
• Immediate ophthalmology referral if no improvement, worsening symptoms, or development of visual concerns 3
• Severe cases can develop pseudomembranes, which are associated with higher rates of severe sequelae including conjunctival/subtarsal scarring, symblepharon, keratitis, dry eye, and lacrimal stenosis 2

When Antibiotics ARE Indicated

While this case does not require antibiotics, you must recognize when they are necessary:

Bacterial Conjunctivitis Considerations

If the presentation were purulent (mucopurulent discharge with eyelids matted shut on awakening), bacterial conjunctivitis would be the diagnosis 5, 4:

• Haemophilus influenzae is the most common bacterial pathogen in this age group, followed by Streptococcus pneumoniae and Moraxella catarrhalis 6, 7
• Oral antibiotics are superior to topical in children with bacterial conjunctivitis, particularly for preventing the "conjunctivitis-otitis syndrome" where up to 30% develop concurrent acute otitis media 6
• Amoxicillin dosing for a 3-year-old with ear/nose/throat infection: 45 mg/kg/day divided every 12 hours for severe infections, or 25 mg/kg/day divided every 12 hours for mild/moderate infections 8
• Treatment duration should be continued for minimum 48-72 hours beyond symptom resolution 8

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral conjunctivitis, as this contributes to antibiotic resistance without clinical benefit 5, 4
• Do not miss corneal involvement by failing to perform fluorescein staining, as adenovirus can progress to EKC with permanent visual consequences 1
• Do not confuse with Kawasaki disease, which presents with bilateral nonexudative conjunctivitis without discharge, but would have additional criteria including prolonged fever, rash, and mucosal changes 1
• Do not assume streptococcal pharyngitis explains the conjunctivitis, as streptococcal infection does not cause conjunctivitis 1