Omphalitis Clinical Presentation
- Author: Patrick G Gallagher, MD; Chief Editor: Ted Rosenkrantz, MD more...
A detailed review of the pregnancy, labor, delivery, and the neonatal course is important when assessing omphalitis. Note the following:
A history of poor feeding or feeding intolerance may be an early indication of infection. A history of change in mental status, such as irritability, lethargy, and somnolence, or a history of a decreased level of activity may be an important indicator of systemic dissemination of the infection.
Anaerobic bacteria are part of the normal flora of the female genital tract and are commonly involved in ascending infections of the uterus and in septic complications of pregnancy; therefore, the higher incidence of omphalitis caused by anaerobes (especially B fragilis) in infants with adverse perinatal histories, such as premature or prolonged rupture of membranes and amnionitis, may relate to exposure to maternal infection.
History of urine or stool discharge from the umbilicus suggests an underlying anatomic abnormality.
Physical signs vary with the extent of disease. Signs of localized infection include the following:
Purulent or malodorous discharge from the umbilical stump
Periumbilical erythema (Recently, algorithms that attempt to standardize the clinical diagnosis of omphalitis have been developed, emphasizing extent of periumbilical erythema and absence or presence of pus.)
The image below shows a case of omphalitis associated with bullous impetigo due to Staphylococcus aureus.
Extensive local disease, with extension
The following signs indicate more extensive local disease, such as necrotizing fasciitis or myonecrosis, which are typically found in a periumbilical location but may spread across the abdominal wall, onto the flanks and back, and into the scrotum. These signs may also suggest infection by both aerobic and anaerobic organisms and include the following:
Ecchymoses, violaceous discoloration
Peau d'orange appearance
Progression of cellulitis despite antimicrobial therapy
The images below demonstrate findings in a case of omphalitis (left) associated with extensive myonecrosis (right).
Signs of sepsis or other systemic disease are nonspecific and include disturbances of thermoregulation or evidence of dysfunction of multiple organ systems. Examples include the following:
Disturbances of thermoregulation - Fever (temperature >38°C), hypothermia (temperature < 36°C), or temperature instability
Cardiovascular disturbances - Tachycardia (pulse >180 beats per minute [bpm]), hypotension (systolic blood pressure < 60 mm Hg in full-term infants), or delayed capillary refill (< 2-3 s)
Respiratory disturbances - Apnea, tachypnea (respirations >60/min), grunting, flaring of the alae nasi, intercostal or subcostal retractions, or hypoxemia
GI tract disturbances - Rigid or distended abdomen or absent bowel sounds
Cutaneous abnormalities - Jaundice, petechiae, or cyanosis
Neurologic abnormalities - Irritability, lethargy, weak sucking, hypotonia, or hypertonia
Omphalitis is a polymicrobial infection typically caused by a mixture of aerobic and anaerobic organisms.
Associated risk factors include the following:
Low birth weight (< 2500 g)
Prior umbilical catheterization
Septic delivery (as suggested by premature rupture of membranes, nonsterile delivery, or maternal infection)
Prolonged rupture of membranes
Omphalitis occasionally manifests from an underlying immunologic disorder. Leukocyte adhesion deficiency (LAD) is most prominent among the immunodeficiency syndromes.[30, 31, 32, 33, 34] Numerous infants with acute or chronic omphalitis have been diagnosed with LAD, a rare immunologic disorder with an autosomal recessive pattern of inheritance. These infants typically present with the following:
Delayed separation of the umbilical cord, with or without omphalitis
Omphalitis may also be the initial manifestation of neutropenia in the neonate.[35, 36, 37, 38, 39] Infants with neonatal alloimmune neutropenia or congenital neutropenia have presented with omphalitis. Neonatal alloimmune neutropenia is a disease analogous to Rh-hemolytic disease and results from maternal sensitization to fetal neutrophils bearing antigens that differ from the mother's. Maternal immunoglobulin G antibodies cross the placenta and result in an immune-mediated neutropenia that can be severe and last for several weeks to 6 months. Affected infants may present with other cutaneous infections, pneumonia, sepsis, and meningitis.
Because omphalitis complicated by sepsis can also be associated with neutropenia, the underlying immune-mediated neutrophil destruction may not be immediately appreciated in affected newborns. The congenital neutropenias are a disease group of heterogenous disorders that range from intermittent to persistent manifestations of varying severity. Omphalitis may complicate congenital neutropenia.
Rarely, an anatomic abnormality such as a patent urachus, patent omphalomesenteric duct, or urachal cyst may be present.[40, 41, 42, 43, 44]
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