Pediatric Emergency Medicine

Pearls & Pitfalls - Acute Hemorrhagic Conjunctivitis

Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine and Pediatrics
Medical College of Georgia

Tara Orlando, MD
Resident, Department of Emergency Medicine
Medical College of Georgia

Pearl: Hemorrhagic conjunctivitis, a rare presentation, is more common in other parts of the world and usually is caused by viral strains that are not prevalent in the United States. Nevertheless, it can occur in the United States and, as shown in this case, can be associated with the Epstein-Barr virus.

Case: A 3-year-old girl presented to the pediatric emergency department with a 5-day history of fever, sore throat, cough, and crusty drainage from her eyes. Her parents reported that her pediatrician had diagnosed Group A streptococcal pharyngitis and infectious mononucleosis two days earlier and had started a five-day regimen of azithromycin. Even though her symptoms were improving, her parents reported the development of bloody drainage from both eyes since the prior evening. The right eye was affected more than left, and bilateral crusting of the eyes was noted. Her past medical history was significant only for seizures, and her current medications included azithromycin and erythromycin ophthalmic ointment. She had no known drug allergies, and her immunizations were up-to-date. A review of systems revealed decreased oral intake, rhinorrhea, cough, eye discharge, and abdominal pain. On examination, her vital signs were: BP 119/74; P 94;T 37.1; RR 36. The patient appeared well-nourished but demonstrated bilateral subscleral hemorrhages and crusting. (Figure 1, Figure 2, and Figure 3) She also exhibited prominent red papillae of the tongue and non-tender cervical Lymph nodes. The abdomen was soft, non-tender, and without organomegaly, and her skin demonstrated no rash, petechiae, or purpura. Her complete blood count and basic metabolic panel (BMP) were within normal limits, but her PTT was prolonged at 60.7, and alkaline phosphatase was elevated to 190 with otherwise normal liver function tests. She was diagnosed with acute hemorrhagic conjunctivitis associated with infectious mononucleosis and discharged home. Follow-up with the eye clinic the following day confirmed the diagnosis and left management recommendations unchanged.

Discussion: Acute hemorrhagic conjunctivitis (AHC) is a rare but highly contagious form of conjunctivitis that in the past has resulted in several epidemics worldwide. Originally described as an epidemic in Ghana in 1969, it has been reported in other countries such as China, India, Japan, Cuba, and most recently in Brazil (2006).1 Epidemics of AHC are most common in developing countries. Seroepidemiology has shown that Coxsackie group A24 (CA24) and Enterovirus E70 (EV70) strains are the most common causative agents.2 Prevalence of AHC in the United States is lower than in developing countries, but the condition has been seen in the Southwest. In this case, however, the patient’s conjunctivitis most likely was caused by the Epstein-Barr virus, the agent of the infectious mononucleosis syndrome. The association of infectious mononucleosis with hemorrhagic conjunctivitis has been reported previously.3,4

AHC is a rapidly progressive and contagious infection. The signs and symptoms of AHC begin after 12-48 hours of incubation and include sudden onset of ocular pain, eyelid swelling, a foreign body sensation, excessive tearing, eye discharge, and photophobia. A fine pinpoint epithelial keratitis also is described. Depending on the stage at which the patient presents, findings may include swollen lids, conjunctival follicles, chemosis, and subconjunctival hemorrhages ranging from petechiae to large areas of conjunctival involvement. The characteristic prominent hemorrhagic component then soon appears. The clinical signs usually start to resolve within 5-7 days and generally disappear in 1-2 weeks. The infection typically is self-limited, and only supportive care is necessary. Sequelae in uncomplicated AHC are rare. Nevertheless, microbial superinfection of the cornea has been described as common, and topical steroids should be avoided.5

In general, the workup in the clinical setting including laboratory testing for AHC is impractical, as the infection has a rapid course and the outcome is most commonly benign. However, if the Epstein-Barr virus is suspected, testing can be accomplished easily. Prevention is the most effective way to deter spread of the disease. Patient education is an important part of managing this condition and should include an emphasis on the importance of personal hygiene and the avoidance of close personal contact with an infected person.


  1. Moura FE, Ribeiro DC, Gurgel N, et al. Acute haemorrhagic conjunctivitis outbreak in the city of Fortaleza, northeast Brazil. Br J Ophthalmol 2006;90:1091-1093.
  2. Goh KT, Ooi PL, Miyamura K, et al. Acute haemorrhagic conjunctivitis: Seroepidemiology of coxsackievirus A24 variant and enterovirus 70 in Singapore. J Med Virol 1990;31:245-247
  3. Kanafani ZA, Bashur Z, Kanj SS. Acute Epstein-Barr virus infection causing bilateral conjunctival hemorrhages. South Med J 2005;98:390-391.
  4. Heiligenhaus A, Dohrmann J, Koch J, et al. Severe bilateral panuveitis in a patient with asymptomatic Epstein-Barr virus infection. Eye 2001;15:792-793.
  5. Yin-Murphy M, Baharuddin-Ishak, Phoon MC, et al. A recent epidemic of Coxsackie virus type A24 acute haemorrhagic conjunctivitis in Singapore. Br J Ophthalmol 1986;70:869-873..


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