August 2005

A 6-day-old female neonate is brought to the emergency department for the second time in three days with worsening swelling of the medial aspect of the left eye (figure 1). The onset was a few days earlier. Her mother’s pregnancy, labor and delivery was unremarkable, as well as the baby’s nursery course. Specifically, there was no history of maternal herpes, parvovirus or any other sexually transmitted disease. The baby had been feeding well and had no history of fever or other concerns.

Examination revealed a normal-appearing baby with the swelling noted above. Some yellowish drainage was noted in the medial canthus of the left eye (figure 2), which was cultured during the first visit and grew Staphylococcus epidermidis.

What’s Your Diagnosis?

1. Dacryocystitis
2. Preseptal cellulitis
3. Dacryoadenitis
4. Oculoglandular syndrome of Parinaud

Answer

This is a case of dacryocystitis, an inflammation or infection within the lacrimal duct or, as in this case, the lacrimal sac, resulting in inflammation and swelling anywhere between the medial corner of the eye to the side of the nose, as shown in the 9-year-old in figure 3. It begins as a result of obstruction somewhere along the path of the duct. One may find a purulent-appearing discharge into the affected eye with or without associated conjunctivitis. One can also usually express some of the exudate for culture purposes by applying gentle pressure in an upward direction on the duct and sac. However, this should be done very carefully as injury to the structure may result. I would recommend referring all newborns, like the one presented, to an ophthalmologist for treatment. I’m told that most of those cases in young infants need probing, which of course is best managed and followed by an ophthalmologist. In fact, I refer all cases to an ophthalmologist.

Antimicrobial therapy is also an area of debate. It usually depends on the presence of signs of significant inflammation and the organism recovered (if any). In the case presented, a coagulase-negative staph was recovered, and minimal inflammation was observed. Therefore, drainage and probing by an ophthalmologist is likely all that will be needed. Based on the appearance of the case seen in figure 3, on the other hand, will probably need antibiotic therapy in addition to drainage. The choice should ideally be based on culture and sensitivity results, but initially an anti-staph product should be selected. Nowadays, that probably means an antimicrobial effective against methicillin-resistant Staphylococcus aureus (MRSA), like clindamycin. But, like most superficial abscesses, once drainage is accomplished, resolution will quickly follow with or without antibiotics. If a secondary bacterial conjunctivitis results, a topical antimicrobial may be needed, and obviously, the more serious secondary cellulitis will need treatment, probably intravenous.

Lastly, it is important to consider the source of the obstruction. A variety of anatomic defects can interfere with normal drainage through the duct, and again, this is best evaluated by eye specialists. The most common is, of course, lacrimal duct stenosis; however, a tumor or other mass may also obstruct. If a mass is suspected (figure 4, a 20-month-old with a facial myxoma), CT or MRI imaging may be helpful prior to referral (figure 5 of the patient in figure 4).

Choice “C,” dacryoadenitis, is an infection or inflammation with swelling of the lacrimal gland, which is located in the lateral aspect of the upper lid. Therefore, when it swells, for whatever reason, it deforms the lid into an “S-shape,” as shown in figure 6, a patient with trauma-induced dacryoadenitis.

Preseptal cellulitis can be spontaneous (bacteremic spread), secondary to sinusitis or traumatic (figure 7). It is usually easy to differentiate preseptal cellulitis from uncomplicated lacrimal duct infections.

Oculoglandular syndrome of Parinaud is the coincident occurrence of conjunctivitis with regional adenitis, usually preauricular (figure 8). There is typically a granulomatous nodule under the upper lid (figure 9, which is a different patient with oculoglandular syndrome due to cat scratch disease). The most common cause is the organism Bartonella henselae. However, in a patient who appears more febrile and toxic, one should think of tularemia.

There are a variety of other, much less common causes that can be considered. Those causes and everything else mentioned above can be reviewed in the very nice chapter (10) by Gonzalo Vicente and Barrett Katz, ophthalmologists at The George Washington University Medical Center in Washington, in the new (11th) edition of Krugman’s Infectious Diseases of Children, 2004, edited by Anne A. Gershon, Peter J. Hotez and Samuel L. Katz. This new and expanded version of this classic pediatric infectious disease text remains one of the best single-volume works on this subject. It is well written and directed toward the primary care provider for quick reference to the common problems encountered in practice. In the wake of the terrorist events of recent years, the editors have added pertinent subjects such as an updated chapter on smallpox, which had almost disappeared from most references published prior to Sept. 11, 2001. I am the proud owner of an autographed copy of the 7th edition of this textbook, published in 1981 when I was a fellow under Jim Bass. In those days, Saul Krugman and Sam Katz wrote it all, in a very popular, 607-page text. I always enjoyed the tables and other illustrations that seemed to be unique to Krugman’s book, especially his chapter on febrile exanthems. Now, the book has many excellent contributors and 1,037 pages, and a bargain at $89.

Dr. Krugman was professor and chairman emeritus of the department of pediatrics at New York University (NYU) Medical Center. Dr. Krugman died Oct. 26, 1995, at the age of 84, one month after retiring from NYU, but will live on through those he trained and influenced throughout his very important career. If you have an interest in medical history, and would like to know more about Dr. Krugman, I would recommend going to the NYU Frederick L. Ehrman Medical Library Internet Web site at http://library.med.nyu.edu and find your way to the featured collections section, or just “Google” Saul Krugman. It will be the first site that comes up.

Comments

Start now to identify your high-risk patients for influenza vaccine and get your order in early. The season will be here before you know it. Also, please stay alert and support our troops, as well as all our civilian law enforcement personnel. The risks to them are higher than ever. Lastly, the patient shown in figure 6 above was featured in the December 1989 issue of Infectious Diseases in Children. Let’s see, that’s about 16½ years ago. My, how time flies. I think I’ll go lay down.