Dacrocystitis in a Teenager?

Patient Presentation
A 13-year-old female came to clinic with a history of swelling medially on her left eye for the past 2 days. She said that it was painful but it improved after expressing some “pus” from the area when she pushed on it. She had had some facial trauma about 4 days prior to this when she was hit on the nose playing volleyball. She had some bruising but had not sought care. She endorsed increased tearing but had no redness or irritation of the eye. Her vision was normal and she had no problems moving her eyes. She denied any fever, chills, nausea, changes in mentation, rhinorrhea, facial or dental pain.
The past medical history was positive for a chalazion on the left eye about 2 years previously.

The pertinent physical exam revealed a well appearing female with normal vital signs. Along the lateral area of the nose/medial area of the left eye she had a 1 cm red/purplish mass. It was not warm but was just slightly tender. No pus could be seen after palpation of the area. The puncta looked clear. There was no conjunctival or scleral injection. Extraocular movements were normal and pupils were 3 mm and reacted briskly to light. Her nose had normal structures with some bruising at the bridge without abnormal discharge. Teeth had no pain with tapping.

The diagnosis of of dacrocystitis was made. Because this seemed mild but in an older child, ophthalmology was consulted by phone. They agreed to starting antibiotics and followed her up the next day. She continued to do well and this eventually resolved. It was felt this occurred because of swelling due to the nasal injury.

Discussion
Tears are produced in the lacrimal gland which resides in the upper outer quadrant of the eye. The tears flow across the eye medially and are collected in the superior and inferior puncta which drain into their respective canaliculi, and these drain into a common canaliculus. Tears then pass through the valve of Rosenmuler into the lacrimal sac where they are collected. Tears then pass through the nasolacrimal duct, through the distal valve of Hasner and into the nasal cavity. Vascular connections are extensive in this anatomic area and veins do not have valves. Therefore infections can spread easily through direct or indirect spread from the nasolacrimal duct system to other adjacent systems.

Dacrocystitis is an inflammation of the nasolacrimal sac that is usually caused by obstruction, leading to tear stagnation which then provides a good environment for proteinaceous material to form and infectious organisms to propagate. Dacrocystitis can be acute or congenital or acquired and acute or chronic. Congenital dacrocystitis is usually due to obstruction or stenosis in the distal anatomy particular the valve of Hasner. “Before delivery [of an infant] the nasolacrimal system is filled with amniotic fluid. When the amniotic fluid fails to be expressed forom the nasolacrimal system, it becomes purulent with a few days of delivery and becomes pathologic.” Acquired disease is caused by trauma, surgery, foreign bodies, neoplasms or medications. Chronic disease is due to chronic obstruction due to a systemic disease such as sarcoidosis or lupus erythematosus. Acute disease is usually due to an acute infectious cause with Staphylococcus(most common) species, Streptococcus species, Haemophilus influenzae and Pseudomonas aeruginosa being the most common causes. Polymicrobial infections are also common.

Not surprisingly given the pathophysiology and causes of dacrocystitis, there is a bimodal distribution with cases occurring around birth (mainly congenital and more acute) and then again in adults > 40 years old (acquired and may be acute or chronic).

Diagnosis is usually clinical. Symptoms can occur over hours to days. The area around the medial canthus swells and is tender and usually erythematous or even more purple colored. Purulent material can sometimes be expressed from the puncta. There often is an increase in tears which may also cause conjunctival injection. Constitutional symptoms such as fever or elevated inflammatory markers may be present but aren’t necessary for diagnosis. A full examination of the ophthalmologic and nasal structures is important. Culture of purulent material may be helpful to identify an offending organism. Imaging of the anatomic area may be necessary if there is extensive disease or involvement of the posterior orbital structures or complications are suspected. Potential morbidities can be severe with mortality a possibility as well because of the number of important structures that lie adjacent to this area including orbital cellulitis, meningitis, brain abscess, cavernous sinus thrombosis, lacrimal duct fistulas, sinusitis, or permanent vision loss.

Learning Point
Acute dacrocystitis can be a very serious infection and especially younger patients may need more evaluation or treatment. All require close monitoring. Congenital dacrocystitis usually resolves by 6 months. Nasolacrimal duct probing or intubation or balloon dacroplasty or stenting may be necessary depending on the underlying cause and types of previous treatment. Sometimes a dacrocystorhinostomy may be necessary.

The differential diagnosis includes:

  • Capillary hemangioma
  • Cellulitis – preseptal or orbital
  • Dacroadenitis – or inflammation of the nasolacrimal sac
  • Dacrocoele
  • Dermoid cyst
  • Ectropian or eversion of the lower lid
  • Encephalocoele
  • Sebaceous cyst
  • Sinusitis
  • Severe acne or medical chalazion usually can be eliminated as possibilities but in the right circumstances can be considered.

Questions for Further Discussion
1. What causes general eyelid swelling? A review can be found here
2. What is the difference between a hordeolum, chalazion and stye? A review can be found here
3. List emergencies related to the eye.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Eye Infections and Tears.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Ali MJ. Pediatric Acute Dacryocystitis. Ophthalmic Plast Reconstr Surg. 2015;31(5):341-347. doi:10.1097/IOP.0000000000000472.

Chung SY, Rafailov L, Turbin RE, Langer PD. The microbiologic profile of dacryocystitis. Orbit. 2019;38(1):72-78. doi:10.1080/01676830.2018.1466901.

Taylor RS, Ashurst JV. Dacryocystitis. In: StatPearls. StatPearls Publishing; 2021. Accessed April 5, 2021. http://www.ncbi.nlm.nih.gov/books/NBK470565/.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are Some Indications for Using Dexamethasone?

Patient Presentation
An 18-month-old male came to clinic after a bad night where he had sudden onset of a harsh, seal-like cough and difficulty breathing. The mother had taken him into the bathroom and made a steam bath which helped to calm him. He was able to drink and eventually go back to sleep but did awaken several times and needed the mother’s help to go back to sleep. “I’ve done this before, but he was up all night. We got a medicine for his brother once and that’s why I came in – to see if we can get some,” she said. He had a runny nose for the 24 hours before but was eating/drinking well and had no fever or other symptoms. He went to a group childcare and there was one child with similar symptoms. There were no known COVID-19 contacts. The past medical history was non-contributory.

The pertinent physical exam showed a slightly tired male with growth parameters in the 50-90%. His respiratory rate was 24 with an oxygen saturation of 97-99%. His voice and cry were hoarse sounding. He had moderate rhinorrhea. The rest of his examination was normal. The diagnosis of croup was made. The toddler was given one dose of dexamethasone in the clinic to help prevent worsening symptoms. Symptoms to monitor for were reviewed with the mother.

Discussion
Corticosteroids are a group of drugs which can be naturally or synthetically produced. Naturally occurring substances are produced in the adrenal gland, and are protein-bound (primarily corticosteroid-binding globulin and albumin). In the target tissues, they may need to be converted to an active substance. They are then reduced, oxidized, hydroxylated or conjugated as measures to inactivate them. Synthetic steroids have less protein binding and depending on their structure are more or less resistant to inactivation. Prednisone is the glucocorticoid most often used for treatment, especially as it has a short half-life. Prednisone must be converted to prednisolone to create any glucocorticoid effect. Asthma, acute severe dermatitis (e.g. poison ivy), chronic dermatitis (e.g. atopic dermatitis) are common uses of it for the primary care provider.

Systemic corticosteroids comparison:

  • Short acting
    • Cortisol or hydrocortisone, cortisone acetate
    • Lasts 8-12 hours
    • Anti-inflammatory activity = hydrocortisone is considered the standard
  • Intermediate
    • Prednisone, prednisolone, methylprednisolone, triamcinolone
    • Lasts 12-36 hours
    • Anti-inflammatory activity is increased 4-5 times, therefore an equivalent dose is less than hydrocortisone dosing (specific dosing must be checked)
  • Long acting
    • Betamethasone, dexamethasone
    • Lasts 36-72 hours
    • Anti-inflammatory activity is increased ~30 times, therefore an equivalent dose is substantially less than hydrocortisone dosing (specific dosing must be checked)

Topical steroids are also commonly used by primary care providers.
Their percutaneous absorption and therefore the overall potential efficacy depends on several factors:

  • Specific corticosteroid and its bioavailability
  • Vehicle – ointments generally are more potent than creams, lotions, gels, solutions or foam. A review of these vehicles can be found here.
  • Skin barrier integrity and/or inflammation – irritated, inflamed or broken skin has increased absorption
  • Surface area – more surface area increases absorption
  • Occlusive dressings – use under occlusal dressings increases absorption
  • Anatomic area – areas with thin epidermis have increased absorption (e.g. eyelids, face, genitalia)
  • Frequency and duration of use – more frequent or longer use increases absorption
  • Age – infants and young children’s skin has increased absorption

A fingertip unit (FTU) is the “amount of ointment or cream expressed from a tube with a 5 mm diameter nozzle, applied from the distal skin crease to the tip of the index finger of an adult” is about 0.5 grams. FTU is a convenient way to measure the amount of topical medication being applied.
The general topical dosing in FTUs for an adult is:

    One hand – 0.5
    One arm – 3
    One leg – 6
    One foot – 2
    Trunk (front or back) – 7
    Face and neck – 2.5

A review of croup can be found here.

Learning Point
Dexamethasoneis a synthetic, fluoridated, potent glucocorticoid which has little mineralocorticoid effect. It is metabolized by the liver, excreted mainly in the urine and has a half-life of ~ 3 hours. Onset of action is rapid if given intravenously. It is available in tablets, oral solution or injectable suspension. Dexamethasone decreases white blood cell proliferation and migration and causes capillaries become less permeable. Various inflammatory proteins are inhibited and it also increases pulmonary circulation and surfactant production.

Some uses for dexamethasone include:

  • Acute hypersensitivity/allergies
  • Altitude sickness
  • Cancer treatment
  • Cerebral edema
  • Croup
  • Extubation
  • Inflammation, other
  • Multiple sclerosis
  • Prenatal maternal use before delivery of premature infants
  • Shock
  • Testing for Cushing syndrome
  • Spinal cord compression due to cancer metastasis

Side effects include:

  • Insomnia – most frequently reported
  • Immune suppression
  • Cardiac – arrhythmias, increased blood pressure
  • Central nervous system – increased intracranial pressure, pseudotumor cerebri, anxiety, depression
  • Dermatologic – acne
  • Endocrine/metabolic – adrenal suppression, hypothalmic-adrenal axis suppression, hyperglycemia, hypokalemia
  • Gastrointestinal problems – weight gain, anorexia, indigestion, nausea, emesis
  • Genitourinary – spermatogenic changes
  • Ophthalmologic – glaucoma
  • Orthopaedic – bone marrow suppression
  • Pulmonary – pulmonary edema

Contraindications include cerebral malaria, systemic fungal infections, or hypersensitivity. Dexamethasone should be used with caution with many underlying renal, gastrointestinal or myasthenia gravis diseases. Latent infectious diseases can be activated due to immune suppression. Use during pregnancy has an associated risk of increased oral clefts in the fetus. Use of live-virus vaccine administration is often delayed if dexamethasone or systemic corticosteroids are being used.

Questions for Further Discussion
1. Why are systemic corticosteroids usually tapered when discontinuing the medication?
2. What are indications for consultation with a pharmacist?
3. What are some mineralocorticoid effects?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Steroids and Croup.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Riney LC, Shah M, Lopez Domowicz DA. Visual Diagnosis: An Adolescent Male With Severe Facial Swelling and Scalp Infection. Pediatr Rev. 2015;36(11):e39-42. doi:10.1542/pir.36-11-e39.

Sarinho ESC, Melo VMPP. Glucocorticoid-induced Bone Disease: Mechanisms and Importance in Pediatric Practice. Rev Paul Pediatr. 2017;35(2):207-215. doi:10.1590/1984-0462;2017/;35;2;00007.

Scott SM, Rose SR. Use of Glucocorticoids for the Fetus and Preterm Infant. Clin Perinatol. 2018;45(1):93-102. doi:10.1016/j.clp.2017.11.002.

Gates A, Johnson DW, Klassen TP. Glucocorticoids for Croup in Children. JAMA Pediatr. 2019;173(6):595-596. doi:10.1001/jamapediatrics.2019.0834.

Nieman LK. Pharmacologic Use of Glucocorticoids. UpToDate. Updated 3/2/2019, Accessed 2/25/21.

Goldstein BG, Goldstein AO. Topical Corticosteroids. Use and Adverse Effects. UpToDate. Updated 2/10/20, Accessed 2/25/21.

Johnson DB, Lopez MJ, Kelley B. Dexamethasone. In: StatPearls. StatPearls Publishing; 2021. Accessed March 2, 2021. http://www.ncbi.nlm.nih.gov/books/NBK482130/.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Which Premature Infants Need Eye Exams?

Patient Presentation
An 81-day-old former 28 week gestation female came to the resident continuity clinic after her neonatal intensive care unit stay. She had required ventilation for almost 4 weeks and currently was on 1/2 L/minute of supplemental oxygen. She had slowly worked up on her oral feeding and was currently taking ~45-50 ml every 2-3 hours of 24 kcal/ounce premature infant formula. Her parents reported that she was still slow to eat but was continuing to improve as she grew. She had gained 16 grams/day since discharge 2 days previously. She was being followed for Zone III retinopathy of prematurity (peripherally) bilaterally.

The pertinent physical exam showed a small infant with a weight of 2.713 grams (3-10%), 45 cm length (50%) and head circumference 32 cm (10-50%). Percentiles are for the Fenton premature infant growth chart. She was alert and responsive with good tone. Her oxygen canula was in place. The examination was as expected for a former premature infant who was now 39-40 weeks corrected gestational age.

The diagnosis of a former premature infant was made. The following week she was to see ophthalmology and return to clinic for another followup appointment. The attending pediatrician said to the resident, “You probably know more about which babies get eye exams than I do. I’m not sure when they get them, but I know they need them and I help the families to followup.” The family already had a visiting nurse and oxygen therapy already coming to their home, and her neonatal infant followup appointment was already scheduled.

Discussion
Retinopathy of prematurity (ROP) is a developmental problem. Term infants have full vascularization of the retina and therefore cannot have ROP. Premature infants however do not have full vascularization (which proceeds from the periphery to the central retinal area) and therefore may have abnormal and excessive vascularization. It affects premature infants primarily < 31 weeks gestation. Although the mechanism of ROP is not completely understood, increased oxygen levels are a risk factor. Additionally there is data which shows growth factors such as vascular endothelial growth factor (VEGF) are increase,d resulting in abnormal vascularization. Prevention is the best treatment for ROP which includes lower oxygen saturation targets (current targets are in the low 90s%) and proper parenteral nutrition. With cryo- and laser therapy, the outcomes for premature infants with lower rates of any ROP and especially severe ROP have dramatically improved. ROP treatment depends on the location and extent of the disease, and type of disease. Location closer to the macula, more retinal area involved and “plus” disease (i.e. which has abnormal dilation and tortuosity of the retinal blood vessels) all have worse prognoses.

Ablative treatment with laser or cryotherapy or use of anti-VEGF medications (anti-vascular endothelial growth factor) are the usual treatments.

Learning Point
According to the American Academy of Pediatrics (AAP) the following infants should be screened for ROP:

  • All infants with
    • Birth weight of < 1500 grams, OR
    • Gestation age < or = 30 weeks
  • Selected infants
    • Birth weight 1500 – 2000 grams, OR
    • Gestational age > 30 weeks
    • AND are believed to be at risk for ROP (“…infants with hypotension requiring inotropic support, infants who received oxygen supplementation for more than a few days, or infants who received oxygen without saturation monitoring” as determined by the neonatologist or attending pediatrician.

Examinations should be done by an ophthalmologist with pupillary dilation. With advanced ROP, pupillary dilation may be poor so care should be taken if considering using multiple drops to achieve dilation. First examination should occur around 31-34 weeks corrected gestational age depending on initial gestational age. “One examination is sufficient only if it unequivocally reveals the retina to be fully vascularized in both eyes.” Followup examination is determined by the classification of the infants findings. Primary health care providers can support these infants and families by ensuring appropriate followup has been scheduled and assisting families in going to their appointments.

Questions for Further Discussion
1. What are the best growth charts to use? A review can be found here
2. How long do you follow late premature infants for? A review can be found here
3. What are risk factors for bronchopulmonary dysplasia? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Premature Babies and Retinal Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Fang JL, Sorita A, Carey WA, Colby CE, Murad MH, Alahdab F. Interventions To Prevent Retinopathy of Prematurity: A Meta-analysis. Pediatrics. 2016;137(4). doi:10.1542/peds.2015-3387

Fierson WM, American Academy of Pediatrics Section on Ophthalmology, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists. Screening Examination of Premature Infants for Retinopathy of Prematurity. Pediatrics. 2018;142(6). doi:10.1542/peds.2018-3061

Higgins RD. Oxygen Saturation and Retinopathy of Prematurity. Clin Perinatol. 2019;46(3):593-599. doi:10.1016/j.clp.2019.05.008

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Common are Co-infections with Trichomonas and Bacterial Vaginosis?

Patient Presentation
A 16-year-old female came to adolescent clinic with a 2 day history of foul-smelling vaginal discharge and vulvar irritation. The discharge amount was increasing. The color was “whitish” and the consistency she couldn’t describe. She had a new male sexual partner for the past week. She used Depo-Provera® for birth control and usually used condoms as well, but had not with the new partner. The last sexual contact was 2 days before the increasing discharge. She denied any new soaps, lotions or personal hygiene products or new laundry products. She usually wore tight fitting pants consistent with the current style. She had no fever, chills, nausea, emesis, and urinary changes. Her last menses was 18 days ago. The past medical history showed she had been tested for sexually transmitted infections (STI) including HIV.

The pertinent physical exam showed a healthy female with normal vital signs. Her abdominal examination was negative. Her external genitourinary examination showed general irritation of the vulva and perineum. There was a thin discharge at the introitus. She declined speculum examination.

The laboratory evaluation included a wet prep that was positive for whiff test, vaginal pH = 5.0 and showed clue cells. No protozoa were seen. She agreed to testing for Neisseria and Chlamydia as well and these were eventually negative. The diagnosis of bacterial vaginosis and possible trichomonas was made. She was treated with metronidazole and counseled about use of condoms and other STI prevention measures including contacting her new partner. She was to followup within 2-3 months.

Discussion
Vulvovaginitis is a common gynecological complaint for females of all ages. It is specifically the inflammation of the vulva and vagina but is used as a general term often to mean vulvar irritation, itching, and burning that can occur with or without vaginal discharge. In prepubertal females there is lack of estrogenization, and less lactobacillus species which creates a more neutral pH (normal vaginal pH is < 4.5), lack of pubic hair and fat pad which provide trauma protection, location of anus close to the vagina and tendency of poor hygiene in young children. With puberty, estrogen thickens the vaginal tissues and more lactobacillus species lowers the vaginal pH which makes a more hostile environment for other infections.

The differential diagnosis of vulvovaginitis changes depending on the pubertal status and can be reviewed here.

Learning Point
Bacterial vaginosis (BV) is one of the most common causes of vaginal discharge and irritation in adolescents and adult women. In adolescents prevalence is > 20%. BV is caused by a change in the normal vaginal flora with a decrease in lactobacillus and an overgrowth of facultative anaerobic organisms. These organisms include Garnerella vaginalis, Atopobium vaginae, Bacteroides species, Fusobacterium species, Mycoplasma hominis, Peptostreptococcus, Ureaplasma species and others. Studies suggest that with the increased vaginal pH, Gardnerella more easily adheres to the vaginal epithelium creating a biofilm which also may increase the risk of other STIs to occur if exposed. BV is not a specific STI but occurs more often in sexually active people. The risks of BV increase after puberty, with new or multiple sexual partners, lack of condom use, douching or absence of lactobacilli. BV presents as a thin, whitish-grey vaginal discharge that usually has a “fishy” odor. Diagnosis is made with 3 of 4 criteria which include presence of characteristic discharge, positive amine “whiff” test which smells like fish with the addition of potassium hydroxide (KOH) to a vaginal wet prep, vaginal pH > 4.5 (normal 3.8-4.5) and > 20% clue cells (i.e. vaginal epithelia cells that have a stippled appearance because of adherent bacteria). Gram stain is considered the gold standard for diagnosis and various commercial testing is available. Depending on practice location commercial testing may be easier to perform. Untreated BV is associated with preterm labor, irregular menstrual bleeding and pelvic inflammatory disease. Treatment is usually with metronidazole orally or vaginally with clindamycin (orally or vaginally) or tinidazole orally as alternatives.

Trichomonas vaginalis (Trich) is also a common infection for adolescent females. It is the most common non-viral STI. Protozoa infect genital squamous epithelial cells from contaminated genital secretions and is considered an STI. Co-infection with BV is very common and reported to be up to 60-80%. Trich is often asymptomatic (70-85%) but may present as a malodorous, frothy profuse discharge with irritation and pruritis. Like BV, vaginal pH is > 4.5 and on speculum exam small cervical hemorrhages create the “strawberry cervix” appearance. Vaginal wet preparation may show motile protozoa but a negative wet prep does not rule out the infection. Untreated trich can progress to urethritis or cystitis, and in pregnant women is associated with preterm delivery. Treatment is with metronidazole or tinidazole with sexual partners also treated.

Questions for Further Discussion
1. What STIs need to be reported to public health in your area?
2. How common is pelvic inflammatory disease and what are common organisms that cause it?
3. What other health problems are caused by changes in the biome or creation of a biofilm?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Vaginitis and Vulvar Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Tamburini S, Shen N, Wu HC, Clemente JC. The microbiome in early life: implications for health outcomes. Nat Med. 2016;22(7):713-722. doi:10.1038/nm.4142

Loveless M, Myint O. Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. Best Pract Res Clin Obstet Gynaecol. 2018;48:14-27. doi:10.1016/j.bpobgyn.2017.08.014

Lanis A, Talib HJ, Dodson N. Prepubertal and Adolescent Vulvovaginitis: What to Do When a Girl Reports Vaginal Discharge. Pediatr Ann. 2020;49(4):e170-e175. doi:10.3928/19382359-20200317-01

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa