I.
Viruses
Mumps, measles, influenza, Epstein-Barr virus, herpes zoster, herpes simplex
II.
Bacteria
Staphylococci, streptococci, Neisseria gonorrhoeae, Mycobacterium tuberculosis, Mycobacterium leprae, Treponema pallidum, Chlamydia trachomatis, Lymphogranuloma venereum
III.
Fungi
Phycomycetes
IV.
Parasites
Schistosoma haematobium, Onchocerca volvulus
Acute dacryoadenitis is an infection of the lacrimal gland characterized by pain, tenderness, and swelling of the lacrimal gland. The disease is usually unilateral associated with eyelid swelling, ptosis, and erythema. The lacrimal gland palpebral or orbital portion may be involved. Patients may have conjunctival injection and chemosis with watery mucoid discharge in patients with bacterial dacryoadenitis. On the other hand, patients with viral dacryoadenitis such as mumps have no discharge and are associated with swelling of the parotid glands. The most commonly encountered organisms in bacterial dacryoadenitis include Staphylococcus species, Streptococcus species, Haemophilus influenzae, and Neisseria gonorrhoeae. In patients with N. gonorrhoeae, the purulent discharge is profuse. Localized abscess of the lacrimal gland may be seen. In cases of involvement of the orbital lobe of the lacrimal gland, there is slight proptosis with inferomedial displacement of the globe. Patients may have diplopia and compromised extraocular motility. Preauricular lymphadenopathy and facial cellulitis may occur. Patients may develop fever or malaise. In patients with dacryoadenitis caused by Vaircella zoster virus, the skin lesions may show evidence of cutaneous vesicular eruptions along the lacrimal nerve, a branch of the first division of the trigeminal nerve.
4.4.2 Laboratory Diagnosis
Patients with dacryoadenitis should have imaging of the orbit with computed tomography and diagnostic B-scan ultrasonography. The adjacent bony fossa is not affected in these cases. Magnetic resonance imaging (MRI) may be ordered. In infectious dacryoadenitis, efforts should be made to identify the etiologic agents. Cultures of the discharge should be obtained. Complete blood count and differential and blood cultures may be taken. Laboratory confirmation may not be necessary when typical systemic or cutaneous findings suggest the diagnosis of mumps or herpes zoster ophthalmicus. Blood specimens for Epstein-Barr virus may be obtained in suspected cases of infectious mononucleosis dacryoadenitis. Care must be taken to rule out the possibility of other diseases such as benign mixed tumor or adenocarcinoma of the lacrimal gland. Chest x-ray or CT scan, interferon-gamma release assay (IGRA) and Purified Protein Derivative (PPD) skin testing should be done. Serologic tests for syphilis should be performed. The differential diagnosis of dacryoadenitis should include noninfectious inflammatory condition such as Sjögren’s syndrome, benign lymphoepithelial lesions, sarcoidosis, amyloidosis, Graves’s disease, lymphoma, and leukemia.
4.4.3 Treatment
Treatment of viral dacryoadenitis is symptomatic. In patients with herpes simplex or herpes zoster infections, the treatment of choice is oral valacyclovir 1 g twice daily for a period of 1 week. In patients with bacterial dacryoadenitis, the organism should be identified and cultured from the upper fornix or from draining abscess. Discharge should be taken and subjected to Gram stain and cultures. The sensitivity of the organism should guide the treatment. Empiric therapy may be started if Neisseria gonorrhoeae is suspected; Ceftriaxone 1 gm intramuscularly. daily for 5 days should be given together with doxycycline 100 mg orally twice a day. Alternative therapy includes azithromycin 500 mg orally daily for 2 weeks. Staphylococcus aureus infections may be treated with vancomycin, Haemophilus influenzae may be treated with Ampicillin with clavunate or cefuroxime, and streptococcal dacryoadenitis is treated with Augmentin or first-generation cephalosporins. Chronic dacryoadenitis caused by tuberculosis should be treated with antituberculous drugs including isoniazid, pyrazinamide, and rifampin (Chapter 2 Table 2.1).
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