Once inoculated, EBV replicates in the naso- and oropharyngeal epithelium, and then spreads rapidly to neighboring lymphoid tissues such as tonsils, adenoids, and nasal mucosae . In children, nasolacrimal anatomy is small and such an inflammation can induce nasal mucosal congestion, and therefore an acute obstruction of the nasolacrimal duct. Thus, tears are not properly drained through the Hasner valve and have a tendency to accumulate in the lacrimal sac [1, 2].
Stagnation of secretions, whatever the cause, can result in secondary infections with respiratory pathogens (most frequently Streptococcus pneumoniae, Haemophilus influenza, or Staphylococcus aureus) [2, 7, 9]. Clinically, pain and tenderness increase and the infection may extend and diffuse to adjacent tissues. For this reason, antibiotic therapy (systemic and topical) seems justified and is recommended as first-line therapy for acute dacryocystitis [10, 11].
Antiinflammatory drugs, such as ibuprofen and corticoids can be used in addition to decrease tissue swelling and favor natural tear drainage and evacuation .
It is important to note that acute lacrimal retention can also be caused by dacryoliths, mucus plugs, blood clots, foreign bodies, mucosal stenosis, or bacterial infection with empyema . The real challenge lies in recognizing EBV as the cause of dacryocystitis and differentiating it from acute lacrimal retention of another origin or an abscess. It is essential to perform an accurate diagnosis to choose the appropriate treatment. The most common origin of periorbital cellulitis in the pediatric emergency setting is ethmoiditis or local eyelid abscesses that have very similar clinical presentations with early dacryocystitis . They should also be considered in the differential diagnosis and taken into consideration when treatment strategy is decided. CT imaging can help to identify the cause but can also create confusion by revealing abscess-like lesions that correspond to an inflamed and distended lacrimal sac.
In this case scenario, given the typical localization visible since day 2 (Fig. 1b), a regurgitation on the pressure over lacrimal sac (ROPLAS) test could have been done. This could have helped us to make the diagnostic of acute dacryocystitis and maybe spared the patient a scan. Nevertheless, palpation was very painful and therefore difficult, and the nasolacrimal duct was very congested, almost obstructed, so a regurgitation would probably not have been obtained properly.
In contrast to abscesses due to eyelid infections or sinusitis that often require surgery [10, 12], invasive therapy for pediatric dacryocystitis is controversial. It is reserved for chronic, persistent dacryocystitis, or children presenting with congenital nasolacrimal duct obstruction, which is not the case in EBV-related cases [10, 11]. Percutaneous puncture and drainage is suggested if dacryocystitis is complicated with an adjacent abscess. Nasolacrimal probing, intubation, or stenting are also options but usually discouraged in the acute phase owing to the risk of secondary stenosis . Other invasive therapies such as balloon dacryoplasty, percutaneous dacryocystorhinostomy, or endonasal dacryocystorhinostomy exist but are mostly reserved for adults [13,14,15].
In the case of acute dacryocystitis associated with mononucleosis, there are no clear treatment guidelines. The main goal is to unclog the lacrimal sac and prevent a potential infection. Conservative management (digital massages, intravenous antibiotic therapy, topical antibiotics with or without systemic corticoids) seems to be the consensus approach among specialists [1, 2, 5, 7, 8, 13]. It is of note that antibiotic therapy with aminopenicillins is not indicated if EBV infection is clearly documented because, in 70–90% of these cases, a rash can appear. Pathogenesis of this secondary cutaneous eruption is not fully understood and the causality with antibiotic therapy is debated [3, 5]. Literature is scarce but recommends avoiding surgery in the absence of complications such as preseptal cellulitis, ethmoiditis, cavernous sinus thrombosis, meningitis, and abscess [1, 2, 5, 7, 8]. Invasive treatment seems to be inadequate owing to the risk of cutaneous fistula or postoperative stenosis . In this case, it is important to be aware of the possible ongoing viral fever in a patient undergoing antibiotic therapy, which could encourage unnecessary invasive treatment.
Corticosteroid therapy has only been used in a small number of cases of dacryocystitis, but its effectiveness remains to be proven .