Case in Point: Insights on a "Global" Issue

As an avid reader of Consultant for Pediatricians, I would like to comment on a recently published case involving an 8-year-old boy with an erythematous left eyelid ("Photo Quiz," January 2005, page 24).

The patient had mild upper respiratory tract symptoms for 2 days. His mother had called the pediatrician after her son woke up with a swollen eyelid (Figure). He was afebrile and had no other health complaints. Drs Larzo, Wood, Nield, and Kamat diagnosed periorbital cellulitis (preseptal cellulitis).

I believe the diagnosis was incorrect. Over the past 20 years, I have treated about 20 or more of such cases; the diagnosis appears to be viral dacryoadenitis--a diagnosis rarely made in this country. (It is more common in the European literature.) The location of the swelling in the upper lateral portion of the orbit, the absence of fever or any other symptoms (including any appreciable redness), and the association with an upper respiratory tract infection (URI) all argue in favor of this benign diagnosis. The infection is limited to the lacrimal gland, is almost always unilateral, and always resolves without antibiotics (at least in the patients I have treated). None of the children I have treated for periorbital cellulitis ever appeared as healthy as the youngster in this picture. Also, the patient's age is well above the median for this diagnosis.

----Eugene Jura, MD

We appreciate Dr Jura's comments. We believe that our patient had preseptal cellulitis for the following reasons: 1. He had swelling and erythema of both the upper and lower eyelids. Dacryoadenitis typically presents with swelling and erythema that is localized to the lateral aspect of the upper eyelid where the lacrimal gland is located.

2. Patients with preseptal cellulitis often present with symptoms of URI, and many do not have fever.¹

3. Our patient responded promptly to antibiotic therapy. Patients with viral dacryoadenitis do not respond so promptly.

4. Preseptal cellulitis, although common in younger children, can occur at any age.²

Dacryoadenitis is inflammation of the lacrimal gland caused most often by infection with viruses such as the Epstein-Barr virus and coxsackievirus; occasionally, it can be caused by infections with bacteria such as Staphylococcus aureus and streptococci.¹ Viral dacryoadenitis is associated with flu-like symptoms of fever and malaise, as well as an insidious onset of ocular symptoms. More localized inflammation to the upper lateral eyelid, tenderness on palpation, and even globe displacement inferonasally may be presenting signs. Everting the affected eyelid may reveal an enlarged gland, but this part of the examination is not always possible in a young child.

It can be difficult to differentiate a localized dacryoadenitis from a more diffuse preseptal cellullitis.³ Although seen in younger children, inflammation of the lacrimal gland is more prevalent in teenagers and young adults.

---- Deepak M. Kamat, MD, PhD Professor of Pediatrics Vice Chair of Education Director of the Institute of Medical Education Wayne State University School of Medicine Detroit

References:

REFERENCES:

1.Wald ER. Periorbital and orbital infections.

Pediatr Rev.

2004;25:312-320.
2.Schwartz GR, Wright SW. Changing bacteriology of periorbital cellulitis.

Ann Emerg Med.

1996;28:617-620.
3.

Duane's Clinical Ophthalmology

[book on CD-ROM]

.

Based on: Tasman W, Jaeger EA, eds

. Duane's Clinical Ophthalmology.

Available at:

http://www.lww. com/product/?0-7817-5258-2.

2005.