Chlamydial and Trichomonas rhinitis

Treatment of Chlamydial Rhinitis

General Principles and Prevention

Treatment of chlamydial rhinitis focuses on eradicating the infection with appropriate antibiotics. Systemic therapy is required due to the intracellular nature of Chlamydia. Treatment in adults may sometimes be managed on an outpatient basis, but severe or complicated cases, or treatment in vulnerable populations like infants, may necessitate hospitalization to ensure adequate and intensive therapy. A full course of antibiotics, typically lasting from 1 to several weeks depending on the chosen regimen and severity, is essential. With appropriate treatment, chlamydial rhinitis can usually be cured without long-term complications, and relapses are uncommon if the full course is completed and any concurrent urogenital infection is also treated (along with partners, in adults).

Despite the potential for cure, a frivolous attitude towards chlamydial rhinitis should be avoided due to its potential for complications, especially in infants, and its association with STIs in adults. Preventing the neglect or chronic progression of the infection is important.

Chlamydial conjunctivitis (and potentially associated rhinitis) has historically been linked to outbreaks among visitors of public swimming facilities, leading to terms like "swimming pool conjunctivitis" or "bath/basin rhinitis." This highlights the potential for transmission in inadequately chlorinated water, although this is a less common route than sexual or perinatal transmission. Therefore, individuals diagnosed with active chlamydial infection (e.g., conjunctivitis) should refrain from using public swimming pools until treated. Strict adherence to water chlorination standards in swimming pools is crucial for preventing the spread of such infections.

 

Treatment in Newborns and Infants

Treatment of acute chlamydial rhinitis (and associated pneumonia or conjunctivitis) in young children and infants can be challenging. Topical agents applied to the nose are generally ineffective against the intracellular chlamydial infection.

• Systemic Antibiotics: Oral macrolide antibiotics are the mainstay of treatment.
  • Erythromycin: Historically, erythromycin base or ethylsuccinate (e.g., 50 mg/kg/day in 4 divided doses for 14 days) was commonly used. However, it has gastrointestinal side effects and a risk of infantile hypertrophic pyloric stenosis (IHPS), especially if given in the first few weeks of life.
  • Azithromycin: A shorter course of oral azithromycin (e.g., 20 mg/kg/day for 3 days, or a single dose regimen) is now often preferred due to better tolerance and simpler dosing, though the risk of IHPS, while lower, should still be considered.
• Supportive Care:
  • If bacterial superinfection is suspected to be complicating the chlamydial rhinitis, specific antiparasitic (antibacterial) nasal instillation solutions might be considered, though systemic antibiotics for Chlamydia are primary.
  • Vasoconstrictor nasal drops (e.g., oxymetazoline 0.025% for infants) may be used very sparingly and for a short duration (e.g., only before feeding) to relieve severe nasal obstruction that interferes with feeding. Their effect is short-lived.
  • Gentle aspiration of mucus from the nasal cavity with a bulb syringe before feeding can help improve breathing and feeding.

It is essential to treat the mother and her sexual partner(s) if an infant is diagnosed with chlamydial infection to prevent reinfection and manage the maternal STI.

 

Understanding Trichomonas Rhinitis

Etiology and Clinical Presentation in Newborns

Trichomonas rhinitis is a rare condition caused by infection of the nasal mucosa with *Trichomonas vaginalis*, a flagellated protozoan parasite primarily known for causing trichomoniasis, a common STI. In newborns, Trichomonas rhinitis is acquired perinatally during passage through an infected maternal birth canal. *Trichomonas vaginalis* can be found in the genital tract of more than 25% of pregnant women, many of whom may be asymptomatic.

Neonatal infection with *Trichomonas vaginalis* typically manifests within the first few weeks of life. While respiratory tract involvement is less common than urogenital infection in adults, it can occur. Clinical presentation in newborns often includes:

• Conjunctivitis: Often the first sign, similar to other forms of neonatal conjunctivitis.
• Rhinitis: Typically develops after conjunctivitis, around 3 weeks of age. Symptoms include nasal discharge, which can be watery, mucoid, or sometimes bloody, and nasal obstruction.
• Unilateral Epistaxis (Nosebleed): Bleeding from one side of the nose can be a characteristic feature.
• Nasal Mucosal Changes: Examination of the nasal cavity may reveal diffuse inflammation and sometimes granulation-like changes of the mucous membrane.
• Pneumonia: In some cases, *Trichomonas vaginalis* can also cause pneumonia in newborns, presenting with respiratory distress.

 

Diagnosis and Treatment of Trichomonas Rhinitis

Diagnosis involves:

1. Microscopic Examination: Wet mount preparation of nasal discharge (or discharge from the eyes, or maternal vaginal secretions) can reveal motile trichomonads.
2. Culture: Specialized culture media (e.g., Diamond's medium) can be used to grow *Trichomonas vaginalis*.
3. NAATs: Nucleic acid amplification tests are also available for detecting *Trichomonas vaginalis* and are highly sensitive.

Treatment of Trichomonas rhinitis (and other neonatal trichomoniasis manifestations) in the infant involves systemic antiparasitic medication:

• Metronidazole: This is the drug of choice. The recommended dose for neonates is typically 10-30 mg/kg/day orally, divided into doses, for 5-7 days. The exact dosing regimen should be determined by a pediatrician experienced in neonatal infections.

Historical treatments mentioned, such as ampicillin followed by erythromycin, are not effective against *Trichomonas vaginalis*. Ampicillin and erythromycin are antibiotics used for bacterial infections; Trichomonas is a protozoan. Correct identification of the pathogen is crucial for appropriate therapy.

It is also imperative to treat the infected mother and her sexual partner(s) for trichomoniasis to prevent reinfection and further transmission.

 

Differential Diagnosis of Persistent Rhinitis in Infants

Persistent or severe rhinitis in an infant requires careful evaluation to differentiate between various infectious and non-infectious causes:

Condition	Key Differentiating Features
Chlamydial Rhinitis	Onset typically 1-4 weeks (can be later); persistent nasal congestion/discharge; often associated with conjunctivitis and/or afebrile pneumonia with staccato cough; confirmed by NAAT for *C. trachomatis*.
Trichomonas Rhinitis	Onset around 3 weeks, often after conjunctivitis; nasal discharge, possible unilateral epistaxis; confirmed by microscopy/culture/NAAT for *T. vaginalis* from infant and mother.
Gonococcal Rhinitis	Early onset (first 2 weeks); profuse purulent, sometimes bloody discharge; marked mucosal inflammation; confirmed by Gram stain/culture/NAAT for *N. gonorrhoeae*.
Viral Upper Respiratory Infection (Common Cold)	Common; watery discharge initially, may become mucopurulent; associated with cough, sneezing, mild fever; usually self-limiting.
Bacterial Rhinosinusitis (Secondary)	May follow a viral URI; persistent purulent discharge, congestion; common respiratory pathogens.
Congenital Syphilis ("Snuffles")	Persistent, often bloody or mucopurulent nasal discharge ("snuffles") starting in early infancy; other signs of congenital syphilis (rash, bone changes). Positive syphilis serology.
Allergic Rhinitis	Less common in very early infancy but possible; clear watery discharge, sneezing, nasal itching; often family history of atopy.
Anatomical Abnormalities (e.g., Choanal Atresia/Stenosis)	Presents with severe nasal obstruction from birth (especially if bilateral); cyclic cyanosis with feeding in bilateral atresia. Diagnosed by inability to pass catheter or imaging.

 

When to Consult a Specialist

Consultation with an ENT specialist, pediatrician, or infectious disease specialist is recommended if:

• An infant or newborn develops persistent, severe, or purulent nasal discharge, especially if accompanied by feeding difficulties, respiratory distress, or conjunctivitis.
• Chlamydial or Trichomonas infection is suspected or diagnosed in any individual with nasal symptoms.
• There is a maternal history of untreated Chlamydia or Trichomonas infection during pregnancy and the infant develops respiratory or nasal symptoms.
• Symptoms of rhinitis do not improve with standard care or recur frequently.

Early and accurate diagnosis is crucial for appropriate treatment and prevention of complications, particularly in vulnerable neonatal populations.