November 2002

A 14-day-old female neonate was admitted to the hospital from the well-baby clinic for evaluation and treatment of an infection about the umbilical area. The mother had noticed the redness at least a couple of days earlier, but since the baby continued to nurse well, and was neither febrile nor acting sick, and the erythema had not spread, she did not think anything of it. However, she did notice a somewhat foul odor with some discharge from the navel, but thought that, too, was not unusual. She was doing nothing special to clean the umbilical stump and surrounding area; just washed around it when bathing the baby. The baby was born full-term after a normal pregnancy, labor, and delivery and went home with mother at 24-36 hours of age. Her umbilical stump had been treated with triple dye and came off within a week. Her parents refused the hepatitis B vaccine prior to discharge.

Her family history is unremarkable for sick contacts, but she has five siblings and lives with both parents and has lots of pet and visitor exposure.

Her examination revealed a healthy-appearing 2-week-old female in no acute distress, actively nursing as usual. Her vital signs were normal, with a temperature of 98.9° F. The only note-worthy finding was the erythema of the periumbilical skin as seen in figures 1-3. The area had been cleaned prior to the photographs being taken, but there had been more crusty, foul-smelling material in and about the umbilicus. The rest of her exam was normal. Cultures of the umbilical discharge and blood were taken and are pending. The baby was then empirically treated with ampicillin and gentamicin.

What’s your diagnosis?

1. Funisitis
2. Omphalitis
3. Cellulitis
4. Fasciitis

Answer

My answer is A, funisitis, which some experts describe as a mild cellulitis or inflammation of the periumbilical skin. However, the nomenclature of infections of and about the umbilical stump is very confusing and inconsistent. I was taught the definition John S. Bradley, MD, uses in his chapter on “Wound and Deep-Tissue Infections” in Jenson and Baltimore, Pediatric Infectious Diseases Principles and Practice (2nd ed., 2002, W.B. Saunders, chapter 48, pages 587-595), which is the same as noted above. However, Dr. Bradley also coedits John Nelson’s current edition (15th) of his Pocket Book of Pediatric Antimicrobial Therapy, and there, omphalitis and funisitis are considered together. Perhaps Dr. Nelson wrote that section. In a nice review of omphalitis by Alice H. Cushing, MD, (Pediatr Infect Dis J. 1985;4[3]:282-285), the condition I call funisitis was referred to as “Uncertain Omphalitis,” as opposed to “True Omphalitis,” which I think we all agree is a potentially serious infection involving the deeper umbilical stump and surrounding tissues (figure 4). This has the potential to rapidly spread to adjacent tissues resulting in necrotizing fasciitis, sepsis and possible umbilical vein involvement with spread to the portal vein, resulting in liver abscesses. Dr. Cushing referred to this condition as “Complicated Omphalitis.”

When terminology becomes confusing, I usually refer back to the origin of the word(s) describing the condition to try to sort it out. The word funis comes from the Latin word for rope or cord. The word umbilicus is from the Latin word for navel, which is synonymous with the Greek term omphalus, which referred to a stone in the Temple of Apollo at Delphi and was thought to mark the center of the earth. Apparently this term also referred to the center of the abdomen. Therefore, the funiculus umbilicalis is the term given to the umbilical cord.

I’m a fairly simple-minded person, and it appears to me that given the above definitions, you can just about make up your own term for the condition being discussed. The umbilicus seems to provide the environment that favors bacterial growth and serves as the port of entry for the establishment of infection of the surrounding tissues and possibly the umbilical vein. Since the resulting infection represents a spectrum of infectious complications, it would probably make more sense to have a single term for these infections with a grading system. Whether it is called funisitis, omphalitis, navelitis or umbilicalitis probably doesn’t matter as long as there is a descriptor or grading system, such as grade 1-4 added to it. Grade 1 could be a wet, foul-smelling cord, and grade 4 could be abdominal wall infection with necrotizing fasciitis. Grade 2 could be what the child presented above had, and Grade 3 could be a deeper cellulitis as shown in figure 4, without sepsis or fasciitis. One could add “umbilical vein involvement” separately. The reason to differentiate obviously has to do with therapy.

These are not new conditions. On the contrary, it has been well recognized for a long time as a frequent source or port of entry of bacteria causing neonatal sepsis (Chamberlain. Omphalitis in the newborn. J Pediatrics. 1936;9:215-222). However, modern cord care with triple dye, alcohol, antimicrobial soap and basic hygiene, along with early intervention of wet and/or foul-smelling cords during well-baby check-ups has drastically reduced the frequency of true omphalitis, and therefore neonatal sepsis. Historically, these infections were largely caused by gram-positive cocci, such as Staphylococcus aureus and Streptococcus pyogenes (group A strep). However, Mason et al reported their data in The Pediatric Infectious Disease Journal in 1989 (8:521-525), revealing a larger role for gram-negative organisms in the “true and complicated omphalitis” cases. Therefore, early empiric therapy for “true omphalitis” (or if you’re using my system, it’s grades 3 and 4) should probably consist of a third-generation cephalosporin (cefotaxime [Claforan, Aventis]) plus clindamycin. In a case like the one presented above, good topical care and clindamycin alone is probably all that’s needed. This is usually due to group A strep and/or S. aureus. Clindamycin is a good choice for these, especially with the rising incidence of community-acquired methicillin-resistant staph (MRSA). Most of these MRSA strains are sensitive to clindamycin, but beware of the erythromycin-resistant strains as there has been reported cross-resistance to clindamycin with those isolates. A wet, foul-smelling umbilical stump probably just needs improved hygiene. If there is granuloma formation, which is often the case, cleaning and carefully treating with silver nitrate is usually curative.

I want to emphasize that if necrotizing fasciitis is present, emergent surgical débridement is essential. Antibiotics alone will not be enough.

Surface cultures taken on admission of the patient presented grew both group A strep and S. aureus. Blood cultures were negative. These organisms may or may not represent the cause, but we treated for both. Nelson’s Pocket Book gives an option to treat groups A or B strep with a single dose of 50,000 units/kg of benzathine penicillin along with topical care with triple dye or antibiotic ointment for mild cases like this. We thought at first that she had a granuloma at the base of the umbilicus. However, as we prepared to cauterize it, I looked closer by everting the base by pressing down on the surrounding skin. This revealed the pseudogranuloma to be just skin (figure 5). Obviously, we did not cauterize it.

I hope this helps add some clarity to this spectrum of umbilical infections, but if you are still confused, don’t feel bad, I am too.

Acknowledgement: I would like to thank Mike Weir, MD, the Pediatric Residency Program Director at Scott & White Hospital, for contributing figure 4.