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What's the Diagnosis?

Visual Diagnosis


Angela Myers, MD, MPH | Director, Infectious Diseases Fellowship Program | Medical Director, Travel Medicine | Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine

A 1-month-old girl presents with a right eye erythema and edema, along with yellow drainage over the past two days that has progressed to an inability to open the eye. The patient has not had fever and has been eating and stooling normally. She is mildly fussy, but not irritable or hard to console. Examination reveals edematous right eyelid with overlying erythema concentrated at the medial canthus with ability to express purulent drainage. Scleral injection is noted. Computed tomography did not show proptosis or abscess. 

May 2018 visual diagnosis

Of the following, the most likely diagnosis for this infant is: 
A. Dacryocystitis 
B. Nasolacrimal duct obstruction 
C. Orbital cellulitis 
D. Viral conjunctivitis 

Correct Answer: A

The infant in this vignette was diagnosed with dacryocystitis based on clinical exam (edema and purulent discharge from the lacrimal sac). Dacryocystitis occurs in approximately 3 percent of infants with nasolacrimal duct obstruction, or NLDO. NLDO is typically caused by a membranous obstruction of the distal nasolacrimal duct. Clinically apparent NLDO is common in young infants, occurring in 6-20 percent, and is characterized by intermittent excessive tearing (epiphora), discharge and matting eyelids. This obstruction may lead to chronic, low-grade infection, with exam findings of eye crusting, and lower eyelid skin maceration. While the sclera was injected on exam, the lacrimal sac edema and ability to express purulence makes viral conjunctivitis very unlikely. Orbital cellulitis is a known complication of dacryocystitis and a concern when there is eyelid edema causing an inability to open the eye. However, CT did not show evidence of orbital involvement. 

Dacryocystitis is an acute and severe infection which may progress into lacrimal duct abscess, preseptal or orbital cellulitis, sinus venous thrombosis, bacteremia or meningitis. Patients with dacryocystitis require immediate evaluation and treatment with intravenous antibiotics. A palpable mass may be felt on exam, which may indicate a lacrimal duct abscess, dacryocystocele, or both. Purulence should be expressed, if possible, and cultures should be obtained to target therapy. Gram positive and/or gram-negative organisms are equally identified in one-third of infections.1 The most common organisms include: Streptococcus pneumoniae, viridans streptococci, Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa and Escherichia coli. Candida spp. are an uncommon, but reported cause.1 The culture from the patient in this vignette revealed MSSA and the patient was transitioned to cefazolin followed by oral cephalexin at hospital discharge.

Presence of a dacryocystocele is a common finding in the setting of dacryocystitis. In one study dacryocystitis occurred in 50 percent (16/33) of patients with a dacryocystocele. While most of these patients presented in the first two weeks of life, one-third were older than two weeks at presentation.2 Various strategies to alleviate the obstruction have been utilized. Studies have shown a success rate ranging from 53-100 percent with surgical probing in the acute phase of infection.2,3 When present, abscesses should be drained.

References: 

1. Spectrum and the Susceptibilities of Microbial Isolates in Cases of Congenital Nasolacrimal Duct Obstruction. Usha K, Smitha S, Shah N, et al. J AAPOS. 2006:10:469-72. 
2. The Association of Neonatal Dacryocystocele and Infantile Dacryocystitis with Nasolacrimal Duct Cysts. Lueder GT. Trans Am Ophthalmol Soc. 2012;110:74–93.
3. Clinical Outcome of Probing in Infants with Acute Dacryocystitis—A Prospective Study. Chandra Saha B, Kumari R, Prasanna Sinha B. J Clinical and Diagnostic Reasoning. 2017;11:NC01–NC03.