Chlamydial Conjunctivitis

Aka: Chlamydial Conjunctivitis, Chlamydia Conjunctivitis, Adult Inclusion Conjunctivitis, Neonatal Inclusion Conjunctivitis, Neonatal Inclusion Blennorrhea, Inclusion Conjunctivitis of the Newborn, Cicatricial Trachoma, Inclusion Conjunctivitis

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II. Pathophysiology

  1. See Chlamydiaceae
  2. Organism: Chlamydia Trachomatis subtypes D to K
    1. Contrast with subtypes A to C (Trachoma)
    2. Contrast with subtypes L1 to 3 (Lymphogranuloma venereum)
  3. Neonatal Inclusion Conjunctivitis (NIC)
    1. Transmission during Vaginal Delivery
    2. Conjunctivitis onset 5-14 days after birth
    3. Associated with development of Chlamydia Pneumonia
    4. Initial watery discharge becomes copious and purulent
  4. Adult Inclusion Conjunctivitis (AIC)
    1. Affects <2% with genital tract Chlamydia
    2. Transmission
      1. Sexually Transmitted Infection (oculogenital)
      2. Historical: Non-chlorinated swimming pools (1900)
    3. Acute follicular Conjunctivitis >5 days post-exposure
  5. Contrast with Trachoma
    1. See Trachoma
    2. Trachoma is a non-Sexually Transmitted Disease spread by hand to hand contact between children
    3. Trachoma is the leading cause of blindness in the world (primarily in developing countries)
      1. Results in Eyelid inversion and Corneal scarring progressing gradually over 10-15 years
    4. Trachoma is caused by different Chlamydia strains (Serotypes A to C)
      1. Contrast with the STI vertical transmission Chlamydia Conjunctivitis described here (Serotypes D to K)
      2. However, both demonstrate inclusion bodies on palpebral Conjunctival cell scrapings

III. Signs

  1. May present as subacute case (>4 weeks)
  2. Unilateral Conjunctivitis with hyperemia and mucopurulent discharge (stringy mucous discharge)
  3. Lymphoid follicle formation (also seen in some Viral Conjunctivitis)
    1. Tiny, rice grain size, gelatinous pale bumps on the Conjunctiva at fornix

IV. Labs

  1. Chlamydia Trachomatis testing
    1. Chlamydia DNA Probe or NAAT (better Test Sensitivity) OR
    2. Nasal Swab for Chlamydia Direct Fluorescence Antibody (low Test Sensitivity)
  2. Intracytoplasmic Inclusion Bodies
    1. Historically used to identify Chlamydia Conjunctivitis (replaced by PCR)
      1. Responsible for the Chlamydial Conjunctivitis naming (Inclusion Conjunctivitis)
    2. Microscopy of cell scrapings from the palpebral Conjunctiva (inner Eyelid lining)
      1. Small Basophilic (deep purple) inclusion bodies seen within Conjunctival cells
      2. An inclusion body is a Chlamydia Initial Body (Chlamydia Reticulate Body)
      3. Inclusion bodies are indistinguishable from those seen with Trachoma

V. Causes

  1. Chlamydia Trachomatis
  2. Less common Chlamydia Conjunctivitis causes
    1. Chlamydia pneumoniae
    2. Chlamydia psittaci
    3. Lymphogranuloma venereum

VI. Differential Diagnosis

  1. See Bacterial Conjunctivitis
  2. Trachoma
  3. Epidemic Keratoconjunctivitis
  4. Gonorrheal Conjunctivitis (Newborns)

VII. Management

  1. See Trachoma
  2. Adult Inclusion Conjunctivitis (AIC)
    1. Azithromycin 1 g for 1 dose (or Doxycycline 100 mg twice daily for 7 days) AND
    2. Topical Erythromycin ointment to eye twice daily for 21 days
  3. Neonatal Inclusion Conjunctivitis (NIC)
    1. Erythromycin Base or EES 50 mg/kg/day divided four times daily orally for 14 days

VIII. Prevention

  1. Erythromycin (or Tetracycline) ophthalmic ointment
    1. Applied to newborns eyes within 1 hour of delivery
  2. Sexually Transmitted Disease Prevention
  3. Sexually Transmitted Disease surveillance in Pregnancy

IX. References

  1. Williams (2017) Crit Dec Emerg Med 31(2): 3-12
  2. Yanoff (1999) Ophthalmology, Mosby, p. 1.7
  3. Katusik (2003) Am J Ophthalmol 135(4): 447-51 [PubMed]
  4. Lietman (1999) Ophthalmol Clin North Am 12(1) [PubMed]
  5. Mabey (2005) Cochrane Database Syst Rev (2): CD001860 [PubMed]

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