He was observed with complete resolution within 2 weeks. Anterior uveitis is defined as idiopathic inflammation of the uvea (iris, choroid, and/or ciliary body), causing redness and pain. <>18]/P 21 0 R/Pg 9 0 R/S/Link>> <>27]/P 24 0 R/Pg 9 0 R/S/Link>> The patient should wear his/her own corrective lenses for the exam with distance or near correction as necessary.9 If the patient does not have corrective lenses, a practitioner can perform a VA with pin holes to compensate for refractive error. A subconjunctival hemorrhage is a blood-red discoloration on the white of the eye. Wound Healing Research Unit, Institute of Ophthalmology and Moorfields Eye Hospital, 11-43 Bath Street, London, EC1V 9EL, UK, You can also search for this author in The blood is often very visible, but since it is confined within the conjunctiva, it does not move and cannot be wiped away. Risk factors include systemic diseases (spondyloarthropathies), infectious processes (syphilis, tuberculosis, Lyme disease, toxoplasmosis, herpesviruses, cytomegalovirus), and certain drugs (rifabutin, cidofovir, sulfas, moxifloxacin).26 Patients present with pain, diffuse redness pronounced at the limbus (ciliary flush), consensual photophobia, tearing, and possibly decreased vision. A hyphema is also present in the anterior chamber. Question: can you identify this condition? Thomas PA, Geraldine P. Infectious keratitis. The University of Iowa On day 1 after surgery there was a conjunctival buttonhole and IOP of 4 mmHg. Subconjunctival hemorrhage is a benign and self-limiting condition that often occurs without any obvious trauma to the eye. In a patient with a normal lid examination (or for patients with vesicles on their lid examination), the presence or absence of pain and/or photophobia, response to phenylephrine and topical anesthetics, intraocular pressure, slit lamp examination (including fluorescein), and visual acuity are the most helpful historical and physical findings in distinguishing between mild and serious processes. It can be a relatively small spot or cover a large area of your . Retrobulbar blocks are useful methods of achieving anesthesia for intraocular and orbital surgeries. We describe a small series of patients that exhibited multiple spontaneous inferior subconjunctival haemorrhages in association with a circumferential glaucoma filtering bleb (Figures 1, 2 and 3). The differential diagnosis ranges from routine (subconjunctival hemorrhage) to immediately sight-threatening diagnoses (acute angle closure glaucoma [AACG] or endophthalmitis). Spontaneous inferior subconjunctival haemorrhages in association with Erythema or edema of the skin should raise suspicion for periorbital cellulitis, dacrocystitis, stye, or blepharitis, which may have associated conjunctivitis. His visual acuity remained 6/5, IOP ranged between 14 and 20 mmHg between 1 and 3 years after surgery, and the aqueous drainage bleb remained circumferential. Subconjunctival hemorrhage: risk factors and potential indicators Patients must follow up with ophthalmology within 24 hours to control symptoms, limit inflammatory consequences, and to consider lab work for an underlying cause. It might look scary, but it's usually harmless. Obtain gram stain and culture media (plates & liquid culture media) for aqueous and vitreous (1 set for each). Methods Observational case series. & Khaw, P. Spontaneous inferior subconjunctival haemorrhages in association with circumferential drainage blebs. Tell the oculoplastics fellow or staff the next morning and give them the films. Eye redness is diffuse, with characteristic ciliary flush. Instillation of phenylephrine may help to distinguish between episcleritis and scleritis, since the redness of episcleritis typically improves after phenylephrine. Diagram 3: A close-up of the compressed conjunctival fold, showing a conjunctival vessel crimped in the fold. Right upper and lower lid swelling and ecchymosis with right eye bullous subconjunctival hemorrhage. Most cases do not cause pain or changes in vision, and thus no active management is required. In each episode of bleeding, the blood reabsorbed within a maximum of 2 weeks with no apparent sequelae. Subconjunctival bleeding - Wikipedia IOP in the first 12 postoperative weeks was managed with local massage and suture release. c. Electroretinogram. This appears to be a relatively uncommon complication of glaucoma surgery; we became aware of these cases over approximately 1 year while conducting clinical trials of glaucoma surgery totalling almost 400 patients. While injuries can be isolated to the conjunctiva, conjunctival injury can be the presenting sign of underlying intraocular trauma, including open globe injury. Mimura T, Usui T, Yamagami S, et al. The patient started warfarin therapy in association with cardiac surgery 2 years and 2 months after his right trabeculectomy; he had already had five bleeds when he began warfarin. Response to phenylephrine: Instillation of phenylephrine may exacerbate condition and should not be given, Pupils: Mid-sized or dilated, non-reactive pupil, Pain: Moderate to severe, lasts less than 48 hours, Response to topical anesthetic: Should significantly improve pain, Response to phenylephrine: Redness improves, Visual Acuity: May be decreased if the defect is in the visual axis. <> Treatment modalities include some or all of the following depending on the severity of the burn: The Endophthalmitis Vitrectomy Study (EVS) [2] applies only to post-cataract endophthalmitis. At the 16 month follow-up appointment, his IOP was 16 mmHg, and the bleb was large but no longer circumferential, with the inferior bulbar conjunctiva adherent to the globe and no recurrences of the inferior subconjunctival haemorrhage. b. Optical coherence tomography. Bettin P, Carassa RG, Fiori M, Brancato R . Some suggest alternating 10-15 seconds of firm pressure with release of the pressure to allow perfusion of the central retinal artery. Image courtesy of Asagan, Wikimedia Creative Commons. However, there are certain times when subconjunctival hemorrhages can occur as a manifestation of a more dangerous underlying diagnosis, especially if persistent or recurrent. Image courtesy of Jonathan Trove, MD, Wikimedia Creative Common. Provide firm pressure for 90-120 seconds. Rotate scleral knots posteriorly and bury conjunctival sutures if possible. A subconjunctival hemorrhage is usually painless, although some people may experience a scratchy sensation in the eye. Correspondence to Am J Ophthalmol 2000; 129 (3): 385387. Surv Ophthalmol 1998; 43 (2): 93126. AACG is defined as closure (or narrowing) of the anterior chamber angle, causing elevated intraocular pressure and eventual optic nerve damage.5,27 Risk factors include increased age, female gender (three times more common), Asian ethnicity, shallow anterior chamber, hyperopia, and certain medications (topiramate or sulfa).27 Patients typically present with headache, nausea, vomiting, halos around lights, photophobia, blurred vision, and pain. Image courtesy of Andrew Pearson, MA, MRCP. endobj Atlas of Ophthalmology Treatment and Management of Scleral Disorders. Scleritis. Primary open-angle-glaucoma (POAG) was diagnosed in the left eye in March 2000; xalatan was prescribed but IOP control was inadequate and he was booked for trabeculectomy. Patients with allergic conjunctivitis can be treated with topical antihistamines. - Subconjunctival hemorrhage - Bullous subconjunctival hemorrhage - Scleral rupture - Conjunctival foreign body - Proptosis and chemosis - Ocular findings of carotid cavernous fistula - Zone 2 blunt injury - Open globe with prolapsed uvea - Open globe with extrusion of vitreous - Open globe with prolapsed uvea 3 - Iridodialysis I - Iridodialysis II Bullous subconjunctival hemorrhage - UpToDate Enlarge Download Image Permissions: Left: Patient 1, lateral inferior lid margin and adjacent conjunctiva showing extension of bleb and overhanging conjunctiva. Sub-conjunctival haemorrhage | Moorfields Eye Hospital NHS Foundation Trust you know about treatment options that you have. For corneal abrasions, moderate or severe pain is common, but it usually lasts less than 2448 hours.4, Corneal abrasions are treated with lid eversion to exclude foreign body, lubricating ointment or drops, and topical antibiotics (polymixin B, trimethoprim or polysporin; quinolones for contact lens wearers). Shields SR. Endogenous fungal endophthalmitis. <> Financial Support: Supported in part by MRC Grant G9330070. Loss of red reflex can indicate vitreous hemorrhage or retinal detachment. Conjunctival injury - UpToDate A patients pain will generally improve after instillation of topical anesthetics in processes isolated to the cornea, such as corneal abrasion and early viral or bacterial keratitis. Ophthalmology 2000; 107 (4): 712718. <> Subconjunctival Hemorrhage Article - StatPearls A randomised, double-blind trial of topical ketorolac vs artificial tears for the treatment of episcleritis. Note that the lateral (left) side of the inferior conjunctiva is bullous and is overhanging the lower lid margin. 16 0 obj He had a routine left trabeculectomy with limbus-based conjunctival flap. Le Fort I fractures do not involve the orbit, Le Fort II and III involve nasolacrimal system. Internet Explorer). Bolika M, Kolar G, Vidensek J. Bleb window cryopexy for the management of oversized, misplaced blebs. While we did not specifically address patients with an abnormal lid examination, an EP should consider periorbital or orbital cellulitis, dacrocystitis, or blepharitis with associated eyelid erythema. Other possible explanations include eye rubbing associated with irritated conjunctiva, and traction on a trapped conjunctival fold during REM sleep. 6 0 obj ISSN 0950-222X (print), Spontaneous inferior subconjunctival haemorrhages in association with circumferential drainage blebs. uuid:35cefd09-b329-11b2-0a00-300664020000 Eye 19, 269272 (2005). The complications of microbial keratitis include corneal perforation and extension into the visual axis. Patients with episcleritis are treated with topical lubricants and oral non-steroidal anti-inflammatory drugs.23 Patients can follow up with primary care for continued management and for workup of any underlying cause. Image courtesy of James Heilman, MD, Wikimedia Creative Commons. He was not taking anticoagulant medication or nonsteroidal anti-inflammatory medications. endobj Place the index finger between the globe and the infraorbital rim, elevating the globe. Observational case series. The intravitreal injections only have a shelf life of about 2 hours, so do not order them too early. Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. Depending on the type of anesthetic, a block may last over four hours with a mixture of lidocaine 1% and bupivacaine 0.375%. Subconjunctival hemorrhage. Practitioners should avoid apraclonidine, as it can lead to dilation. Consensual photophobia, though a subjective finding, is suggestive of iritis (anterior uveitis) over superficial corneal processes.3 Corneal abrasions may present with severe pain, but the pain typically subsides in 2448 hours and patients will have a characteristic lesion on fluorescein examination.4 Patients with corneal abrasions from contact lenses should routinely see an ophthalmologist within 2448 hours, especially if symptoms have not improved.4, The EP should determine if the patient has any associated symptoms, such as headache or vomiting, concerning for AACG.5 Symptoms of an upper respiratory tract infection are often associated with viral conjunctivitis.1. Ahmed F, House RJ, Feldman BH. On initial evaluation, visual acuity was 20/20 OU, and slit lamp examination revealed bullous subconjunctival hemorrhage in the left eye. Sean Haynie and Jesse Johnson, MD Courtesy of Carolyn Kloek, MD. Your conjunctiva, the clear membrane that covers your eye . Intravitreal vancomycin: 1 mg/0.1 ml in 1 cc syringe. The propensity for the redundant conjunctiva to be folded on the lower lid by the descending upper lid might be increased by tear film disturbances and associated decreased tear lubrication, and altered conjunctival contour. endobj The safety of topic anesthetics in the treatment of corneal abrasions: A review. Thank you for visiting nature.com. Wagoner, MD. Branching lesions with end bulbs that brightly stain with fluorescein are typical of herpes simplex virus (HSV).19 Small, non-staining vesicles may be the only finding during the first 24 hours of HSV infection, or in patients who are immunocompromised.19 Highly branched lesions without end bulbs are typical of varicella zoster virus (VZV), and these stain less brightly with fluorescein.19 In addition to VZV, these pseudodendrites can be caused by neurotrophic epitheliopathy and Acanthamoeba, but these diagnoses are beyond the scope of the EP.19. include: Subconjunctival hemorrhage - Subconjunctival hemorrhages are described as either flat or bullous and by their size (number of clock hours around cornea). Bacterial keratitis: predisposing factors, clinical and microbiological review of 300 cases. For chemical burns, injury grade is based on exam. Web Privacy Policy | Nondiscrimination Statement, This site uses tracking information. LB, an 80-year-old Caucasian male, had a history of treated hypertension and myocardial infarction, and was taking 75 mg of aspirin daily. Department of Neurology and Department of Ophthalmology and Visual Sciences, 4-0 Silk through tarsal plate + 6-0 Silk for skin, 5-0 Vicryl through tarsal plate and two 7-0 Vicryl sutures for lid margin (vertical matress) and skin, Stent with silicone tubing (leave for 6 months). Acular (ketorolac tromethamine) four times daily for 3 days can help with pain control. sharing sensitive information, make sure youre on a federal I really need some help. J Glaucoma 1999; 8 (4): 247249. Chemical injuries of the eye: current concepts in pathophysiology and therapy. Evert and sweep the lids/irrigate for residual foreign body. As a library, NLM provides access to scientific literature. Appligent AppendPDF Pro 6.3 Quinolone: 1 drop 4-6x/day (prevents infection), Prednisolone phosphate: 1 drop every 1-2 hr while awake to reduce inflammation, Vitamin C: 1-2 gm orally daily to reduce corneal thinning/ulceration, 10% sodium citrate: 1 drop every 2 hr while awake (chelates calcium and impairs polymorphonuclear leukocyte (PMN) chemotaxis), Scopolamine 0.25%: 1 drop three times daily (reduces pain/scarring with anterior chamber inflammation), 10% Mucomyst (n-acetyl-cysteine): 1 drop 6x/day (mucolytic agent and collagenase inhibitor), Doxycycline 100 mg orally twice daily (collagenase inhibitor), Glaucoma drops/oral acetazolamide (Diamox) if IOP elevated. Prum BE, Jr, Herndon LW, Jr, Moroi SE, et al. A P Wells. Assessment and Management of Ocular Trauma - University of Iowa This content does not have an Arabic version. Subconjunctival hemorrhage: MedlinePlus Medical Encyclopedia A new clinical presentation of inferior subconjunctival haemorrhage in association with circumferential blebs is described. Sweep for particulate matter and examine fornices. Skip to content Care at Mayo Clinic Care at Mayo Clinic About Mayo Clinic Request Appointment Find a Doctor Four subsequent episodes of inferior subconjunctival bleeding occurred after this, between 12 and 22 weeks after surgery. Bulk download StatPearls data from FTP. Inspect eyes without placing pressure on the globe (e.g., use Desmarres retractors). endobj d. Standardized ultrasound. <> Part 3. At 5 months after the left trabeculectomy, Mr SG described several episodes consistent with spontaneous inferior subconjunctival haemorrhages. If patient has retrobulbar hemorrhage with decreased acuity, increased IOP, check central retinal artery perfusion; you may need to perform a lateral canthotomy/cantholysis. It is similar to a bruise on the skin. ISSN 1476-5454 (online) Treatment of hyperfiltering blebs with Nd:YAG laser-induced subconjunctival bleeding. The diagnosis of AACG is confirmed with elevated intraocular pressure, which may be elevated as high as 60 mmHg. In the past, I have given the patient's name and birthdate to the pharmacist, and they can look up the patient after they check in. If the globe is ruptured, call the senior resident and finish the history/paperwork while backup is on its way. Circumferential drainage is commonly seen, and may be associated with tear film disturbance, hyperfiltration, and dysaesthesia. Fluorescein: Fluorescein depicts branching pattern with terminal bulbs (HSV), branching with tapered ends (VSV), or diffuse fine keratitis (EKC). Mrs DO was a 67-year-old Caucasian female, also with bilateral POAG. This can be difficult if the patient does not have a hospital number. Treatment includes topical parasympathomimetics (pilocarpine 2%; avoid anything higher than 2%), topical beta-blocker (0.5% timolol; caution in asthmatics, COPD patients, and patients with heart block), carbonic anhydrase inhibitors (acetazolamide, 500 mg IV; avoid in sickle cell patients and possibly in sulfa allergy patients), and alpha agnoists (brimonidine 0.1%; avoid in patients on monoamine oxidase inhibitors). 89 0 obj Make sure the patient has updated tetanus immunization, order IV antibiotics/narcotics/antiemetics, call OR/anesthesia, ask about time of last meal, and prepare admission paperwork. Fluorescein: May reveal dendrites if the underlying cause is HSV. All Rights Reserved Autologous blood injection for late-onset filtering bleb leak. The vessels in episcleritis will constrict and the eye redness will improve; this is not true of scleritis. <>82 0 R]/P 22 0 R/S/Link>> Thanks for your good will and any solution. A Case Report of Bullous Subconjunctival Hemorrhag in Adenoviral Conjunctivitis Bleb reduction and bleb repair after trabeculectomy. Following trabeculectomy in the right eye, a thin cystic bleb developed and no further bleeding occurred in this eye. Galor A, Thorne JE. endobj official website and that any information you provide is encrypted Surgical reattachment of conjunctivochalasis has been reported4,5,6,7 in both the presence and absence of filtering blebs. To describe an association of spontaneous inferior subconjunctival haemorrhages in eyes with circumferential drainage blebs following trabeculectomy. Bacterial and viral keratitis and corneal abrasion/foreign body will have uptake on fluorescein examination. J Glaucoma 2001; 10 (1): 4750. I am very afraid for my life that I can lose it. Sutures - longer near the limbus and shorter toward the central cornea. This content does not have an English version. Instillation of proparacaine or other anesthetic eye drops should significantly improve symptoms if the pain is secondary to a lesion at the corneal or conjunctival surface, such as a corneal abrasion. Approach to diagnosis and initial treatment of eye injuries - UpToDate If antiviral treatment is not initiated, ophthalmologic follow up or consultation should be within 12 hours. The most common local anesthetic mixture is 2% lidocaine with 1:100,000 epinephrine to provide some hemostasis. To describe an association of spontaneous inferior subconjunctival haemorrhages in eyes with circumferential drainage blebs following trabeculectomy. She was sent to Ophthalmology for immediate assessment. Order intravitreal antibiotics immediately. Patients in this trial were randomised to receive either 5-FU or placebo delivered as a 5 min application during the surgery. Proprietary interest statement: The authors have no financial interest related to this manuscript, Wells, A., Marks, J. d. Invasion from a nematode. UpToDate Conjunctivitis. A Seidels test should be performed if there is concern for corneal laceration or globe rupture. I am interested to find out any type of healing that can help me. Entry and exit points - equidistant from the wound edge. blood in the anterior chamber (hyphema). Postoperative medications included cyclopentolate 1%, chloramphenicol and maxidex. Diagrams. An assessment of visual acuity (VA) should be performed in all patients presenting with ocular complaints. DeRidder CA, Berkowitz CD, Hicks RA, et al. endobj Pseudophakic Bullous Keratopathy: - University of Iowa Check for facial sensation (Cranial Nerve V1 = orbit roof and V2 =orbit floor) and trismus (pain and tonic contraction of the muscles of mastication). Ocular Exam General: well-appearing patient in no acute distress Visual Acuity: OD-- Hand motions at 3 feet; OS-- Count fingers at 6 feet Intra-ocular pressure: OD-- 19 mmHg; OS-- 22 mmHg Motility: Orthophoric in primary gaze and full motility, OU. Subconjunctival hemorrhages in infants and children: a sign of nonaccidental trauma. Point tenderness, ecchymosis, malar flattening, lateral canthal downward displacement, V2 hypoesthesia, trismus, malocclusion of jaw, inferior or lateral rim step-off. is marked chemosis (conjunctival edema); in extreme instances, there can be bullous chemosis, in which the bulging, edematous conjunctiva extends . 2022-01-12T11:11:42-08:00 Direct photophobia refers to pain with light shone in the affected eye; whereas, consensual photophobia refers to pain with light shone in the unaffected eye. 2022-01-12T11:11:42-08:00 endobj Avoid placing sutures in the visual axis if possible. over a year ago, trenna560132168 . Patients with multiple episodes of spontaneous inferior subconjunctival haemorrhage following trabeculectomy (with or without antimetabolite) and circumferential blebs are presented. 33 0 obj Subconjunctival Hemorrhage - What You Need to Know - Drugs.com Patient 1, one week after spontaneous inferior subconjunctival haemorrhage with reabsorbing blood. The .gov means its official. In all patients, trabeculectomy surgery was performed superiorly, with a modified Cairns - Watson method. Symptoms Eye This bleeding is the bright red spot that you see on the white of your eye. Ophthalmologic consultation should be sought emergently for continued management recommendations and definitive treatment, usually with laser iridotomy. 01, 2023 Subconjunctival hemorrhage is when one or more blood spots appear on the white of your eye. A subconjunctival hemorrhage happens when a blood vessel leaks or breaks just under the conjunctiva. Differential diagnosis ( inspite of normal tension): occult open globe and orbital injury. In conjunction with the slit lamp examination, fluorescein will identify a corneal epithelial defect, such as a corneal abrasion or a corneal defect associated with a microbial keratitis infiltrate. Hello! The phenomenon commonly known as eye hemorrhage has been duly and thoroughly addressed in the literature, with especial focus on the occurrence of hemorrhage as it relates to three factors: presence of diabetes, sleep patterns, and activity levels. Pull back on the syringe to ensure the needle is not in a vessel, then inject 3-5 cc of anesthetic, palpating the globe to assess for posterior pressure. Staphylococcus aureus, coagulase negative staphylococci, and Pseudomonas aeruginosa are commonly isolated organisms in bacterial keratitis.18,30 Patients present with diffuse redness of the eye accompanied by significant pain, tearing, discharge, and photophobia. Some attending physicians prefer amikacin, due to its somewhat better toxicity profile. Otaka I, Kyu N . bullous myringitis info on wikipedia true. National Library of Medicine Patient SS had primary open-angle glaucoma diagnosed in 2000 and, despite medical treatment with timolol, xalatan, and alphagan, there was poor IOP control and progression of visual fields. The clear membrane that lines the inside of the eyelid and covers the white of the eye is called the conjunctiva. volume19,pages 269272 (2005)Cite this article. In a patient with an acute red eye, herpetic lesions on the skin warrant further investigation for herpes or varicella keratitis by fluorescein and slit lamp examination.8 If there is confirmed or high suspicion for herpes or varicella keratitis patients should be started on oral or topical antivirals in the ED. Aksoy A, Baskan AM, Aslan L, et al. Keay L, Edwards K, Naduvilath T, et al. Additional irrigation as needed until pH is 7.0-7.5. He had no history of bleeding problems. Inflammation is characterized by the presence and density of circulating immune cells (cell) and a foggy appearance to the slit beam (flare) caused by protein leaking into the anterior chamber through inflamed vessels. Based on spinal cord injury studies, methylprednisolone IV can be given: 30 mg/kg loading dose then 5.4 mg/kg/hr for 24 hours (if started within 3 hours of injury) or for 48 hours (if started 3-8 hours after injury). <> A new surgical technique for management of conjunctivochalasis. that your doctor will provide you with more information and that he will let She presented in 1997 and managed with topical medications, but required trabeculectomy in the right eye in January 1999 despite trusopt, betagan, and xalatan treatment. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Do NOT do a MRI scan if an IOFB is suspected. Visual acuity recovered to 6/5. Contact Lens Induced Corneal Ulcer Management in a Tertiary Eye Unit in Oman - A descriptive study. 7-O Vicryl is used for skin and 5-O Vicryl is used for deep closure. Image courtesy of Marc Yonkers, MD, PhD. Examination revealed CF vision, IOP 32, and significant bullous subconjunctival hemorrhage. Subconjunctival Hemorrhage: Causes, Treatment, and Prevention - WebMD http://creativecommons.org/licenses/by/4.0/, http://www.eyeworld.org/article-distinguishing-dendrites. One should also consider non-accidental trauma in a child with SH and no history of vomiting or straining.20,21 Patients with subconjunctival hemorrhage may be reassured and advised to use topical lubrication as needed. Do NOT patch the eye; instruct transferring caregiver NOT to patch the eye. Start 2/3 lateral along the inferior orbital rim (inferior to the temporal limbus) with the needle tip pointing perpendicular to the plane of the patients face. With lid lacerations, look carefully for fat prolapse, lid margin involvement and canalicular involvement. endobj Pain, photophobia, blurred vision, and epiphora develop acutely, with 80% developing bilateral disease within 24 hr. 2. While purulent/mucopurulent discharge is more typical of bacterial conjunctivitis and watery discharge is typical for viral conjunctivitis, this distinction is not entirely reliable.22 One study found that the combination of bilateral eye mattering (crusting), lack of itching, and lack of prior history of conjunctivitis was most predictive of bacterial conjunctivitis.22 Viruses cause the majority of cases of conjunctivitis, most commonly adenovirus.22 Acute bacterial conjunctivitis may be caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenza, Neisseria gonorrhea, Chlamydia trachomatis, or diphtheria.
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