Noah is a seven-day-old infant who is brought in by his parents with a lump below his left eye.
Noah has an uncomplicated antenatal and birth history. He was born at 39+3 via vaginal delivery and has had no other neonatal issues.
His parents noted a very subtle blue discolouration and lump near his medial canthus on day two of life. The lump has progressively grown and became erythematous. He is otherwise well, breastfeeding and putting on weight with no systemic symptoms.
On examination Noah has purulent discharge from his eye and a fluctuant erythematous mass inferior to the medial canthus. Observations are within normal limits.
What is the most likely diagnosis?
Correct!
Acute neonatal dacryocystitis is infection of the lacrimal sac most commonly due to congenital nasolacrimal duct obstruction.
It is a rare condition and typically presents in the first few weeks of life with epiphora, swelling and erythema overlying the lacrimal sac.
Fever and fussy feeding support the diagnosis, however fever is not a good indicator of infection in a newborn as they often do not mount an immune response.
Acute dacryocystitis occurs most commonly as a complication of a nasolacrimal duct obstruction from a dacryocystocele.
Dacryocystoceles are usually noticed in the first few days of life. They present with a bluish lump over the lacrimal sac and occur due to distal and proximal blockage of the nasolacrimal duct. Dacryocystoceles may resolve spontaneously, however they can also progress rapidly to acute dacryocystitis.
Suspected acute dacryocystitis requires urgent admission, broad spectrum IV antibiotics and paediatric ophthalmology review for consideration of surgical management.
Complications include lacrimal sac abscess, cellulitis, septicaemia, meningitis and death. One analysis showed that 27% of infants less than six weeks old with dacryocystitis had bacteraemia on presentation.
Causative organisms are most commonly Staphylococcus aureus and streptococcus species.