How should acute hemorrhagic conjunctivitis be managed in a 2½‑year‑old child?

Management of Acute Hemorrhagic Conjunctivitis in a 2.5-Year-Old

Acute hemorrhagic conjunctivitis (AHC) in a 2.5-year-old requires supportive care only, with strict infection control measures, as this highly contagious enteroviral infection is self-limited and resolves in 5-7 days without specific antiviral treatment. 1

Immediate Clinical Assessment

Rule out bacterial superinfection and serious complications before confirming supportive-only management:

• Examine for severe purulent discharge that rapidly reaccumulates after cleaning—this suggests bacterial superinfection requiring topical antibiotics or possible gonococcal infection requiring immediate systemic treatment 2
• Check for corneal involvement (opacity, infiltrate, ulcer)—any corneal findings mandate urgent ophthalmology referral 3
• Assess pain severity—AHC typically causes severely painful conjunctivitis, but moderate-to-severe pain beyond expected levels warrants ophthalmology evaluation 1, 3
• Look for subconjunctival hemorrhages as the distinctive clinical sign, along with watery discharge and rapid onset 1, 4

Etiology and Natural History

• AHC is caused by Enterovirus 70 (EV70) or Coxsackievirus A24 variant (CVA24v), which are the major etiological agents in worldwide outbreaks 4, 5
• The condition is benign and self-limited, resolving spontaneously in 5-7 days without treatment 1
• No specific antiviral therapy exists for enteroviral AHC 4, 1
• Rare neurological complication: approximately 1 in 10,000 patients infected with EV70 develop polio-like paralysis (radiculomyelitis), though this is exceedingly rare 1

Supportive Care Protocol

Implement the following symptomatic measures:

• Preservative-free artificial tears 4 times daily to dilute viral particles and inflammatory mediators 6, 3
• Cold compresses for comfort and to reduce inflammation 6, 3
• Topical antihistamines (second-generation) may relieve itching and discomfort, though no specific pediatric dosing is standardized in guidelines 6
• Avoid topical antibiotics unless bacterial superinfection is confirmed, as they provide no benefit for viral infection and risk adverse effects and resistance 3

Critical Infection Control Measures

AHC is highly contagious and spreads through direct person-to-person contact, contaminated surfaces, and possibly airborne transmission:

• Strict hand hygiene with soap and water is the cornerstone of preventing transmission 6, 3
• Avoid sharing towels or close contact during the contagious period of 7-14 days from symptom onset 6
• Exclude from daycare/preschool until symptoms resolve to prevent outbreak spread 4, 5
• Sanitize surfaces and ophthalmological materials that may be contaminated 4
• Educate parents and community about the highly contagious nature to prevent undue alarm, discourage home remedies, and control spread 1

When to Refer to Ophthalmology

Arrange immediate ophthalmology evaluation if any of the following develop:

• Visual loss or significant change in vision 3, 6
• Moderate-to-severe pain beyond typical AHC discomfort 3
• Corneal involvement (opacity, infiltrate, ulcer) 3, 6
• Severe purulent discharge suggesting bacterial superinfection or gonococcal infection 2
• No improvement after 3-4 days of supportive care 6, 2
• Immunocompromised state 3, 6

Special Considerations for This Age Group

• Any purulent conjunctivitis in a child under 3 years warrants careful evaluation to exclude gonococcal or chlamydial infection, which require systemic antibiotics 2
• If bacterial superinfection is suspected (copious purulent discharge, worsening symptoms), obtain conjunctival cultures before initiating topical antibiotics 3
• Gonococcal conjunctivitis can cause corneal perforation within 24-48 hours and requires immediate systemic ceftriaxone 25-50 mg/kg IV/IM plus azithromycin 2

Follow-Up Strategy

• Instruct parents to return for evaluation if no improvement after 3-4 days to consider alternative diagnoses or complications 6, 2
• Monitor for neurological symptoms (weakness, paralysis) in the rare event of radiculomyelitis, though this complication is exceedingly uncommon 1
• Reassure parents that the condition is benign and self-limited, with expected resolution in 5-7 days 1

Critical Pitfalls to Avoid

• Never prescribe topical corticosteroids for suspected viral conjunctivitis without definitively excluding HSV, as steroids potentiate HSV infection and can prolong adenoviral infections 3, 6
• Do not use topical antibiotics routinely for viral conjunctivitis, as they provide no benefit and risk toxicity and resistance 3
• Do not delay referral if severe purulent discharge or corneal involvement is present, as gonococcal infection can cause perforation within 24-48 hours 2