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Progressive inflammation of left medial periorbital structures in 3-week-old afebrile neonate
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Richard H. Schwartz
James H. Brien
A 3-week-old boy presents with a red and swollen left eye. His history is that of a 34-week premature, born via uncomplicated vaginal delivery with Apgar scores of 8 and 9, and he remained in the NICU for 1 week due to prematurity. The only NICU complication was physiologic jaundice, which was treated with phototherapy.
At discharge from the NICU, the patient’s examination revealed suspected left nasolacrimal duct obstruction, managed by parental massage of the lacrimal sac and nasolacrimal duct several times per day. However, 2 days after his 2-week post discharge checkup, the infant had the onset of rapidly progressive swelling and erythema involving both the left upper and lower eyelids and the area over the left lacrimal sac. Erythema was noted in a horizontal, sub-palpebral distribution and quickly spread during a 6-hour period, completely closing the eye (Figure 1). The patient’s vital signs were normal, with no history of fever.
Figure 1. Swelling and erythema involving both the left upper and lower eyelids and the area over the left lacrimal sac.
Source: Brien JH
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Case Discussion
The diagnosis is acute dacryocystitis (C), and the patient was admitted to a local children’s hospital for IV antimicrobial therapy. Clindamycin (20 mg/kg in 3-divided doses) was administered for 3 days, followed by 4 days of outpatient oral clindamycin, with complete normalization of the periorbital soft tissues (Figure 2).
Figure 2. Complete normalization of the periorbital soft tissues.
Source: Brien JH
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There is general agreement in the medical literature that rapidly progressive acute dacryocystitis with cellulitis requires hospital admission, especially in young infants, and rapid initiation of IV antibiotics that are effective against Staphylococcus aureus and Streptococcus pyogenes. A pretreatment culture and Gram stain should be obtained on the discharge. Monotherapy with clindamycin is a reasonable empiric choice, but in geographic areas with a small percentage of methicillin-resistant S. aureus, one may chose a first-generation cephalosporin or Unasyn (ampicillin plus sulbactam; Pfizer). However, ongoing treatment should always be culture-directed when possible.
After 3 to 4 days of IV antibiotics, most cases of acute dacryocystitis will rapidly improve with regression of cellulitis and reduction of eyelid swelling; outpatient therapy with an additional 4 days of appropriate antibiotic is usually recommended. Patients should be followed by pediatric ophthalmologists for possible surgical management with probing of the affected lacrimal puncta to achieve patency of the lacrimal sac and nasolacrimal duct.
Most term neonates produce tears that drain via the nasolacrimal system into the nasal cavity. Approximately 10% of neonates have epiphora and excessive mucus discharge caused by common distal nasolacrimal obstruction. Tears enter the lacrimal sac through the lacrimal puncta and exits into the nasolacrimal duct, but may be unable to enter the nasal passage because of the presence of a membrane or obstructing nasolacrimal duct dacryocele (cyst) at the nasal terminus. The distal blockage of the NL duct causes retrograde stasis, overgrowth of bacteria, and low-grade, usually non-serious recurrent eye infections, starting after the first month of life. Signs include crusting of eyelashes, dried mucus at the lacrimal puncta, and moist mucopurulent discharge on surface of the eye and lower eyelid.
The clinical differentiation between the uncommon, but more serious acute dacryocystitis and the common super-infection of an obstructed nasolacrimal duct, as well as acute dacryocystadenitis, are contrasted below:
Acute dacryocystitis begins much earlier in life, often within the first few weeks after birth, progresses quite rapidly, and involves not only the area beneath the eyelid but a discrete swelling over the lacrimal sac. Gentle massage over the infected lacrimal sac may or may not produce discharge of purulent material; if it does, the exudate should be sent for Gram’s stain and culture.
Nasolacrimal duct infection starts at the nasal end (Figure 3). The infection usually occurs after the first month of life, spreads slowly, presents similarly to subacute conjunctivitis with mucoid or mucopurulent discharge crusting and matting of eyelash, and drainage over the medial lacrimal puncta. When the lacrimal sac is gently compressed by the tip of a gloved index finger, there is often mucopurulent material expressed. However, one must be careful not to use much pressure, as this could cause injury to this delicate structure.
Figure 3. Nasolacrimal duct infection starts at the nasal end.
Source: Brien JH
Click the image to enlarge.
Figure 4. A patient who also had orbital extension with dysconjugate gaze.
Source: Brien JH
Click the image to enlarge.
Acute dacryocystadenitis refers to cellulitis, with or without abscess, of the lacrimal gland that produces tears and is located laterally and superior to the eye. With swelling of the gland, the upper lid takes on a characteristic “S-shaped” configuration (Figure 4, a patient who also had orbital extension with dysconjugate gaze).
Lastly, while periorbital (pre-septal) cellulitis is technically correct, and could be the answer, it is not the best answer. For additional discussion of these interesting infections about the eye, with some additional pictures, please see the April 2015 column, featuring another young infant with dacryocystitis.
I would like to thank my old friend, Dick Schwartz, as well as Rebecca Levorson, MD, Lamson D. Nguyen, DO, and Helen H. Yeung, MD, for their contribution to this column.
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- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.