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Photo Quiz

A Boy With Sudden-Onset Left Otalgia and Otorrhea

Volume 59 - Issue 8 - August 2019

  • Answer: AOM due to P aeruginosa with tympanic perforation

    The attending physician, based on antibiotic susceptibility results, began treatment with ciprofloxacin, 0.3% plus fluocinolone acetonide 0.025% otic solution twice daily for 7 days and asked the parent to bring her son back for a follow-up visit in 3 days.

    During the follow-up visit, the patient did not present with ear discharge, and the tympanic perforation had almost closed. Culture test results identified P aeruginosa.

    DISCUSSION

    AOM is one of the most frequent bacterial infections seen in children worldwide.1-4 It affects up to 4 of 5 children by the age of 3 years.2,4 Middle ear bacterial infections frequently originate from the upper respiratory tract due to asymptomatic nasopharyngeal colonization.5,6 Because of a shorter and more horizontal eustachian tube, children are more prone to develop AOM.5 Spontaneous otorrhea occurs in 3.3% to 52% of children with AOM.4

    After the introduction of the pneumococcal conjugated vaccine, which has reduced the burden of pneumococcal disease,3,4 the microbiology of the condition has shifted, and the most commonly involved bacteria are Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus pyogenes, Moraxella catarrhalis, and Staphylococcus aureus.1,3,4,7,8 P aeruginosa is not frequently seen as the pathologic organism of AOM in the developed world, but it is prevalent in developing countries, where can be the culprit in 14.5% to 60% of cases.5,9-14 It frequently causes otorrhea,14 and most cases (32.5%-49%) occur in those younger than 10 years.5,14

    P aeruginosa is an aerobic, gram-negative, motile, non–spore-forming, oxidase-positive, and lactose non-fermenting bacterium that produces pyocyanin and pyoverdine,15 both of which are water-soluble pigments that fluoresce under a Wood ultraviolet lamp (which emits a light radiation between 320 and 400 nm, with a peak at 365 nm) that gives the typical yellow-green color.15,16 P aeruginosa fluorescence is detected if the bacterial load exceeds 105 colony forming units/cm2.15

    The susceptibility of P aeruginosa to ciprofloxacin ranges from 85% to 97%,5,13,17,18 with 2% of strains being resistant.18 However, the widespread use of otic drops has promoted the emergence of P aeruginosa resistant to this antibiotic.19

    The median time for otorrhea cessation using ciprofloxacin/dexamethasone is 4 days, and the improved/cured rate is 93.7% at day 3 and 96.2% at day 11.17

    REFERENCES:

    1. Kung Y-H, Chiu N-C, Lee K-S, et al. Bacterial etiology of acute otitis media in the era prior to universal pneumococcal vaccination in Taiwanese children. J Microbiol Immunol Infect. 2014;47(3):239-244.
    2. Al-Mazrou KA, Shibl AM, Kandeil W, Pirçon J-Y, Marano C. A prospective, observational, epidemiological evaluation of the aetiology and antimicrobial susceptibility of acute otitis media in Saudi children younger than 5 years of age. J Epidemiol Glob Health. 2014;4(3):231-238.
    3. Abdelnour A, Arguedas A, Dagan R, Soley C, et al. Etiology and antimicrobial susceptibility of middle ear fluid pathogens in Costa Rican children with otitis media before and after the introduction of the 7-valent pneumococcal conjugate vaccine in the National Immunization Program: acute otitis media microbiology in Costa Rican children. Medicine (Baltimore). 2015; 94(2):e320.
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