1. Omphalitis and urachal anomalies
Andrew J Seier, MS4

2. 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

3. 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

4. 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)

5. 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.]

6. 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.

7. Abdominal ultrasound

8. 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.

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

10. 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.

11. 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)

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