Omphalitis and urachal anomalies Andrew J Seier, MS4

HPI 5 week-old male Umbilical swelling and erythema Born at 39 4/7 weeks following a GBS (-) pregnancy complicated by GDMA2 methadone use early in pregnancy C/S delivery for decels and failure to progress APGAR 8 and 9 Umbilical stump detached at one week of age, leaving only a small scab

HPI (cont.) Nearly 4 uneventful weeks pass after the umbilical stump detaches Then, swelling under the umbilicus and erythema in a 2-cm border around it PMD evaluates, sends child to OCH ED No history of fever, decreased PO intake, increased fussiness Normal stool output Only other symptom is mild nasal congestion

ED/floor course Abdominal ultrasound performed in ED Immediately following ultrasound there was spontaneous drainage of 10cc of frank pus from the umbilicus Full neonatal sepsis workup initiated, with LP, UA with culture, blood culture, and CBC Given ceftriaxone and gentamicin in the ED Since admission, erythema and swelling have nearly disappeared (over the last 24 hours)

Physical exam Vitals: T 36.7°C, HR 145 BPM, RR 32, BP 88/45, O2 sat 100% on room air Positives Erythema of umbilicus, without palpable mass No erythematous border on surrounding skin; soft and non-tender to palpation Negatives HEENT: [Normocephalic, atraumatic. Nares clear, moist pink mucosa without discharge. No pharyngeal erythema or exudates.] Neck: [Soft, supple, no lymphadenopathy, full range of motion.] Respiratory: [Lungs clear to auscultation bilaterally, no rales, rhonchi, or wheezes. Good air entry bilaterally, with no increased respiratory effort or accessory muscle use.] Cardiovascular: [Regular in rate and rhythm, S1/S2 heard along right and left sternal borders. PMI non-displaced.] Gastrointestinal: [Normal bowel sounds. Abdomen soft, non-tender, non-distended. No hepatosplenomegaly.] Musculoskeletal: [Musculature normal in bulk and tone. No joint swelling, warmth, or tenderness to palpation. Full range of motion of upper and lower extremities.] Skin: [No desquamation, rashes, or lesions.] Neurologic: [Sensation intact throughout. Pupils equal, round, and reactive to light. Extraocular movements intact.]

Assessment This is a 5-week old male infant born of a pregnancy complicated by GDM-A2 with c- section delivery for decels and failure to progres, presenting with umbilical swelling, erythema, and purulent drainage. The infant is otherwise asymptomatic. A full sepsis workup was done in the ED. Cultures of blood, CSF, urine, and the drainage are negative to date.

Abdominal ultrasound

Urachal anomalies Complete patency results in a patent urachus with free communication between the bladder and the umbilicus May present at birth with a giant umbilical cord. Persistent tissue at the umbilicus with no connection to the bladder results in an umbilical polyp Umbilical polyps are firm masses comprised of intestinal epithelium or uroepithelium. They are rare, do not respond to silver nitrate therapy, and require surgical excision. Persistent tissue at the bladder with no connection to the umbilicus results in a bladder diverticulum. Bladder diverticulum can cause ureteral obstruction at the site of bladder insertion. Patent mid-duct with closure at both the umbilicus and the bladder results in a urachal cyst The cyst may become infected with gram-positive skin flora or gram- negative enterobacteriaceae and present with abdominal pain, erythema, or swelling, usually located below the umbilicus.

Case report – NEJM 2016 In this case, cyst did not communicate with bladder Organisms cultured were coagulase- negative staph and E. coli

Definitions Funisitis Omphalitis Omphalitis with systemic sepsis unhealthy umbilical stump, malodorous, and/or purulent discharge Omphalitis abdominal wall cellulitis: periumbilical erythema, superficial tenderness Omphalitis with systemic sepsis Omphalitis with fasciitis umbilical necrosis with extensive local disease, periumbilical ecchymosis, crepitus bullae, and evidence of involvement of superficial and deep fascia Wilson, C. B. (2016). Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant (8th ed.). Elsevier.

Organisms involved MSSA or MRSA Group-A strep vs group-B strep Historically (before chlorhexidine rinse and sterile technique) E. coli, Klebsiella, Proteus If foul-smelling purulent discharge, then anaerobes such as B. fragilis, C. perfringens, C. tetani Guidelines for antibiotic therapy: an anti- staphylococcal penicillin (such as oxacillin) or vancomycin if MRSA is suspected + an aminoglycoside (such as gentamicin)

Summary Important to know underlying anatomy of the umbilicus Infected urachal cyst vs omphalitis Surgical management for excision of urachal remnants