A 3-year-old girl is brought to your clinic by her mother, who is concerned about her daughter’s worsening eye redness, tearing, and lid swelling of 1 month’s duration. Per parental history, the girl is a constant eye rubber. On exam, in addition to the ocular findings described by the mother, you notice some mild scaly skin inside the elbows and on the upper eyelids. The patient’s past medical history is also significant for a nut allergy.

What is the most likely diagnosis?

A. Ocular rosacea.

B. Viral conjunctivitis.

C. Bacterial conjunctivitis.

D. Molluscum contagiosum.

E. Atopic conjunctivitis.

The correct answer is “E.” The patient has several signs pointing to atopic conjunctivitis. She has scaly skin at locations typical for atopic dermatitis (eczema). Her persistent eye rubbing is another indicator and may be secondary chronic papillary conjunctivitis. In addition, she has a history of nut allergy, which is common in atopic patients. The distinction between allergic and infectious conjunctivitis mostly comes from the history. Patients with allergic conjunctivitis often have seasonal symptoms or have other systemic findings consistent with allergies (either annual or perennial). Infectious conjunctivitis is usually acute, self-limited, and associated with mucopurulent or purulent discharge, whereas, allergic conjunctivitis is chronic, recurrent, and associated with clear discharge. It is common for patients with allergic conjunctivitis to have shiners under their eyes. Infectious processes may or may not be associated with fever, otitis media, or upper respiratory infections, which would not be the case in a patient with an allergic conjunctivitis.

Sources:

Question & Explanation: Peterson AR, Wood KE. Pediatrics Examination and Board Review. New York, NY: McGraw-Hill Education; 2017.

Photo: Tenenbein M, Macias CG, Sharieff GQ, Yamamoto LG, Schafermeyer R. Strange and Schafermeyer's Pediatric Emergency Medicine, 5e; 2019.