LAUSR

A 15-year-old male presented to our pediatric emergency department (PED) with a chief complaint of left eye redness for 1 week. The patient denied trauma or known foreign bodies. The eye redness had worsened throughout the week prior to presentation and was associated with significant tearing. He also endorsed a small amount of blood on his hand after wiping his eye 3 days prior to presentation. Associated symptoms included photophobia and blurred vision due to pain and tearing. Pertinent negatives included the absence of pain with extraocular movements, vision loss, recent fever, weight loss, weakness, headache, dizziness, facial pain, neck pain, shortness of breath, cough, hemoptysis, vomiting, abdominal pain, diarrhea, joint pain, or rash. He denied significant medical history and was not on any medications. He was unaware of any recent sick contacts. The patient emigrated from Micronesia to the United States 1 month prior to presentation. On presentation to the PED, his vital signs were within normal limits for age. On examination, he was anxious appearing but in no acute distress. He preferred to hold his left eye shut. Inspection of his eyes revealed significant left conjunctival injection and copious tearing. There was no swelling of the lids. His pupils were equal, round, and reactive to light bilaterally without opacity. Extraocular movements were intact and did not elicit increased pain. There was no proptosis. Visual inspection did not reveal a foreign body. On the margin of his cornea and sclera, a small 4to 5-mm fleshy appearing nodule was visible with slight stromal haze (Figure 1A). The remainder of his examination was unremarkable. Ophthalmology was consulted and examined the patient in the PED. The examination, which included slit-lamp testing (Figure 1B), was concerning for phlyctenular conjunctivitis (PKC). A chest X-ray was performed and read as follows: “small focal illdefined opacity in the left midlung may represent an early infection, atelectasis, or scarring, and ill-defined speckled opacity in the right lung apex suspicious for fibrotic scarring from previous pulmonary tuberculosis (TB).” A purified protein derivative (PPD) skin test was placed; quantiferon-TB gold test (QFT) was obtained; and he was discharged to home with close outpatient follow-up on ophthalmic prednisolone drops and ophthalmic erythromycin ointment. His PPD (22 × 24 mm of induration with 5-mm blister and >40 mm of surrounding erythema) and QFT were subsequently positive (Figure 2).