Umbilical Discharge in a 3-week-old Boy

A 3-week-old boy, born at term via an uncomplicated vaginal delivery at an urban hospital, presents to a pediatric emergency department (ED) with a 3-day history of purulent umbilical discharge that is now resolved and a new 1-day history of fever (maximum temperature, 100.4°F [38°C]). His umbilical discharge was spontaneous and intermittent and had prompted 2 other health-care encounters. The first was a call to a telehealth service on day 1 of illness, who advised them to clean the umbilicus with chlorhexidine. The second was to the ED on day 3 of illness, where he was well-appearing and during the visit his father recorded a video of the umbilical discharge, although this video was not viewed by the ED physician and the discharge was not present at the time the physician examined him (Video). He was diagnosed as having a possible umbilical granuloma and was discharged with an outpatient referral to general surgery for silver nitrate application.He returns to the ED the following day, day 4 of illness, due to a new fever. His mother reports that he has been increasingly fussy and has some abdominal distention, but the umbilical discharge stopped the previous day. He is feeding, voiding, and stooling well, and review of systems is negative for abnormal movements, symptoms of an upper respiratory tract infection, respiratory distress, vomiting, and rash. His mother’s pregnancy was uncomplicated; she had adequate antenatal care, and she was not colonized with Streptococcus agalactiae. During delivery, there was no prolonged rupture of membranes, maternal fever, or other sepsis risk factors. The baby’s birthweight was 3,500 g, and he is growing well along the 80th percentile. No substances were applied topically to the baby’s umbilical stump, which separated on day 4 after birth. There were no previous episodes of umbilical discharge. There are no methicillin-resistant Staphylococcus aureus (MRSA) risk factors identified on history.In the ED, the baby appears well with the following vital signs: axillary temperature, 100.8°F (38.2°C); heart rate, 185 beats/min; respiratory rate, 40 breaths/min; blood pressure, 115/76 mm Hg; oxygen saturation, 96%. He is warm and well-perfused. The chest is clear. The heart sounds are normal. The abdomen is soft, nontender, but mildly distended, with no umbilical erythema, induration, or discharge. He is circumcised, and both testes are descended without appreciated hydrocele. He has normal tone and is moving all limbs spontaneously.A full evaluation for sepsis (blood culture, urine culture, lumbar puncture for cell count, protein, glucose, and culture) is performed; however, lumbar puncture is unsuccessful after 5 attempts. Laboratory investigations reveal the following values (reference ranges): hemoglobin, 13.9 g/dL (139 g/L) (10.0–15.5 g/dL [100–155 g/L]); leukocytosis (white blood cell count, 27,000/µL [27 × 109/L] with 13,400/µL [13.4 × 109/L] neutrophils); platelet count, 432 × 103/µL (432 × 109/L) (150–600 × 103/µL [150–600 × 109/L]); elevated C-reactive protein, 6.49 mg/dL (64.9 mg/L) (≤1.0 mg/dL [≤10 mg/L]); and urinalysis with 2+ blood, 2 to 5 white blood cells, but negative for glucose, ketones, protein, nitrites, and leukocytes. An abdominal radiograph demonstrates a nonspecific gas pattern, but no signs of obstruction or necrotizing enterocolitis. He is started on ampicillin, tobramycin, and acyclovir at doses sufficient to treat a central nervous system infection and is admitted to pediatric medicine. His blood culture, urine culture, and respiratory virus multiplex results are negative.Subsequently, abdominal ultrasonography with Doppler is performed on his third day of admission on revisiting his history of purulent umbilical discharge and abdominal distention, which reveals the diagnosis (Fig).This neonate’s presentation in the ED of fever and tachycardia is concerning for sepsis. Maintaining a broad differential diagnosis as to the source of infection in a febrile neonate is crucial to avoid the cognitive error of premature closure. His umbilical discharge was not considered to be a sign of an occult infection initially because it had resolved the day before admission and before the onset of his fever. The differential diagnosis of umbilical discharge can be narrowed based on age at presentation and physical examination findings, including discharge appearance, associated skin changes, or umbilical cord abnormalities. For instance, an umbilical granuloma often presents as a painless red/pink, glistening mass at the umbilicus with serous or serosanguinous drainage and is usually readily distinguished by these characteristics from omphalitis. (1) Similarly, intermittent watery discharge with bubbles from the umbilicus may represent urine passed via a patent urachus. (2) The umbilicus is a highly active area embryonically, and as a result, several tissue planes converge there postnatally. (2)(3) Incomplete regression of embryonic structures, such as urachal remnants and omphalomesenteric remnants, can also become infected and should be included in the differential diagnosis of a neonatal intra-abdominal collection. (4) Purulent discharge from the umbilicus is concerning for omphalitis and infection of the deeper structures of the umbilical cord. These infections can be complicated by sepsis, intra-abdominal abscess, peritonitis, thrombophlebitis, necrotizing fasciitis, and death. (5)(6)(7) Some of these complications can occur without external evidence of omphalitis. (6)(8) It is important to consider the umbilical stump as a source of infection in febrile neonates with no obvious localizing symptoms.Ultrasonography reveals a 5.6 × 2.0 × 1.7-cm collection surrounding and following the trajectory of the regressing umbilical vein (ie, ligamentum teres), concerning for an infection (Fig). Infectious diseases is consulted, and his current antibiotics are replaced with cefotaxime and cloxacillin (comparable with oxacillin) at standard dosing. Drainage of the collection is performed by interventional radiology, which yields 2 mL of thick, green, purulent fluid, which grows MRSA in pure culture.Omphalitis is an infection of the umbilicus and surrounding tissues. It occurs primarily in the neonatal period, with a mean age at presentation of 3.2 days. (9) Deep-space complications of omphalitis were once a common cause of neonatal mortality, but the practice of aseptic umbilical cord care has decreased its incidence profoundly. (3)(10) Omphalitis still occurs in low- or middle-income countries, with an incidence of up to 22%, due to reduced adoption of aseptic cord care practices as well as application of traditional medicines and substances (such as cow dung, oils, herbs, or clays) to the umbilicus, (11)(12)(13) although the incidence of deep-tissue complications is not well-characterized. In high-income countries, deep-tissue complications of omphalitis are rare and have mostly been limited to home births. (3)(14) In this patient’s case, there was no external evidence of omphalitis, but the perivascular collection following the course of the umbilical vein toward the liver suggested a deeper tissue infection with an initial portal of entry at the umbilicus.After birth, the umbilicus presumably becomes quickly colonized with Staphylococcus and Streptococcus species, followed by enteric organisms such as Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis. (15) The devitalized necrotic umbilical stump promotes bacterial growth, and omphalitis can develop due to 1 or more of these bacteria. (7)Common signs and symptoms of omphalitis include erythema, tenderness, induration, and purulent or serous discharge of the umbilicus or surrounding tissues. Omphalitis may remain localized; however, it can rapidly progress to systemic infection or lead to severe complications as a result of spread to deep tissues via the potential spaces and tissue planes of the abdominal wall and regressing umbilical vessels. Early recognition and treatment of omphalitis and its complications is important to prevent morbidity and mortality. The most common of these complications is sepsis, which may be polymicrobial. Necrotizing fasciitis, a surgical emergency, should be suspected if there is rapid progression of the infection or failure to improve with intravenous antibiotics. Other complications include peritonitis, thrombophlebitis of the umbilical or portal veins, septic umbilical arteritis, intestinal gangrene, intra-abdominal abscess, and endocarditis. (5)(6)(7)Risk factors for omphalitis include home birth, low birthweight, maternal infection, prolonged rupture of membranes, umbilical catheterization, and improper cord care. (12)(16)(17) In low- and middle-income countries, topical chlorhexidine has been shown to be an inexpensive method to reduce risk of omphalitis and its associated morbidity and mortality. (18)Broad-spectrum parenteral antibiotics covering gram-positive and gram-negative organisms are required when deep-tissue complications of omphalitis are suspected, such as necrotizing fasciitis, septic embolism of umbilical vessels, liver abscess, and peritonitis. (5)(6)(7) In settings where MRSA prevalence is high or there is a history of maternal MRSA colonization or infection, vancomycin should be considered empirically until culture results can guide therapy. The duration of antibiotic therapy is determined based on the extent of the infant’s infection, any complications present, and the clinical response.The baby remained well throughout his hospitalization, and his fever abated after 2 days of empirical intravenous antibiotics (ampicillin, tobramycin), 3 days before interventional radiology drainage. His abdominal distention improved over time. His antibiotics were changed from cefotaxime and cloxacillin to vancomycin alone after cultures from the collection yielded MRSA. Repeated abdominal ultrasonography 5 days after the drainage showed interval improvement of the collection, and his elevated white blood cell count and C-reactive protein level had normalized. After 5 days of vancomycin therapy, he was transitioned to oral trimethoprim/sulfamethoxazole. He was discharged with repeated abdominal ultrasonography and follow-up at the infectious diseases clinic in 1 week. At his infectious diseases clinic follow-up, he was well, was afebrile, and had no abdominal distention or umbilical discharge. His repeated abdominal ultrasonography showed further, but not complete, interval improvement of the collection. He was seen again in 2 weeks, with a repeated abdominal ultrasonography demonstrating continued improvement of the collection, and antibiotics were discontinued; the total antibiotic duration was 28 days. Another abdominal ultrasonography performed 4 weeks after antibiotic discontinuation showed resolution of the collection.Deep-tissue complications of omphalitis, once a common cause of neonatal mortality, still occur.Treatment for deep-tissue complications of omphalitis includes empirical broad-spectrum antimicrobial coverage until a pathogen is identified, with duration tailored to the clinical improvement of the patient.When managing neonates with fever of unknown origin, a degree of suspicion for uncommon diagnoses, including the umbilical stump as a source of infection, should be maintained to avoid the cognitive error of premature closure.

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