Dacryoadenitis

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Disease

Inflammation of the lacrimal gland is called dacryoadenitis.

Etiology

The most common etiology for dacryoadenitis is viral infection, with Epstein-Barr virus being the most common viral cause. Less common viral causes include adenovirus, varicella zoster, herpes simplex, rhinovirus, cytomegalovirus or mumps.

Bacterial causes include Staphylococcus aureus,

Besides infection, other etiologies include inflammatory causes such as non-specific orbital inflammation (NSOI), IGG4-related disease, or sarcoidosis, or neoplastic causes such as lymphoma, adenoid cystic carcinoma, or pleomorphic adenoma.

Risk Factors

Potential risk factors include exposure to viral or bacterial agents or the presence of autoimmune disorders including Sjögren's syndrome, sarcoidosis or IgG4-related disease.

Diagnosis

Signs

Right-sided dacryoadenitis in a young man.
Right-sided dacryoadenitis in a young man.

Signs of dacryoadenitis include tenderness, edema, or erythema overlying the superolateral orbit, conjunctivitis with or without chemosis, regional lymphadenopathy, proptosis of the globe. Fever may be present.

Symptoms

Symptoms of dacryoadenitis include pain in the superolateral orbit, pain with eye movements, ptosis or difficulty opening the affected eye, redness of the eye, and possibly diplopia.

Diagnostic procedures

A contrast-enhanced computed tomography (CT) scan of the orbits will typically demonstrate enlargement of the affected lacrimal gland with enhancement. There may be associated fat stranding.

If sarcoidosis is suspected, a chest radiograph is a reasonable screening tool to evaluate for lymphadenopathy or pulmonary disease.

Laboratory tests

Although there are no specific laboratory tests for dacryoadenitis, depending on the clinical context, it may be of use to obtain a complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), and/or C-reactive protein (CRP) level to evaluate for leukocytosis and systemic inflammatory response. If autoimmune etiology is suspected, additional labs could include antinuclear antibody (ANA) screen, SS-A/SS-B antibodies, and serum IgG4 level.

Management

Medical therapy

Depending on the severity of the presentation, therapy could range from warm compresses to empiric treatment of bacterial infection, with or without the addition of systemic steroids.

Follow up

Close follow up is warranted if there are orbital signs including decreased visual acuity, pain with eye movements, relative afferent pupillary defect, or abnormal color vision.

Surgery

Although typically reserved for severe or recurrent cases, a biopsy of the lacrimal gland may be of diagnostic value if the etiology is in question.[1]

Complications

There is limited data on complications of dacryoadenitis, however one case series reported ptosis affecting some patients, as well as a measurable (but clinically insignificant) decrease in tear production.[2]

Prognosis

The prognosis of dacryoadenitis is generally good, with variability depending on the etiology. Viral dacryoadenitis is typically a self-limited disease, whereas idiopathic dacryoadenitis is more heterogeneous. One case series of 79 patients reported poor response to treatment in 37% of patients with idiopathic dacryoadenitis, and recurrent disease in 15% of the patients.[3] The same series found that male sex and inflammation extending to an extraocular muscle were risk factors for incomplete treatment response, and that patients with bilateral dacryoadenitis had an increased risk of recurrent disease.[3]

Additional Resources

Rhem MN, Wilhelmus KR, Jones DB. Epstein-barr virus dacryoadenitis. Am J Ophthalmol 2000;129:372-5.

Foster WJ Jr, Kraus MD, Custer PL. Herpes simplex virus dacryoadenitis in an immunocompromised patient. Arch Ophthalmol 2003;121:911-3.

Obata H, Yamagami S, Saito S, et al. A case of acute dacryoadenitis associated with herpes zoster ophthalmicus. Jpn J Ophthalmol 2003;47:107-9.

Galpine JF, Walkowski J. A case of mumps with involvement of the lacrimal glands. Br Med J 1952;1(4767):1069-70.

Kiratli H, Sekeroglu MA, Soylemezoglu F. Unilateral dacryoadenitis as the sole presenting sign of Wegener's granulomatosis. Orbit 2008;27(3):157-60.

Dutt S, Cartwright MJ, Nelson CC. Acute dacryoadenitis and crohn's disease: Findings and management. Ophthal Plast Reconstr Surg 1992;8(4):295-9.

Witmer, M. (2009, August 13). Unraveling the Difficult Diagnosis of Dacryoadenitis. Retrieved from https://www.reviewofophthalmology.com/article/unraveling-the-difficult-diagnosis-of-dacryoadenitis

References

  1. Luemsamran P, Rootman J, White VA, Nassiri N, Heran MKS. The role of biopsy in lacrimal gland inflammation: A clinicopathologic study [published correction appears in Orbit. 2018 Apr;37(2):158]. Orbit. 2017;36(6):411-418. doi:10.1080/01676830.2017.1352608
  2. Alexandre Robin, Toufic Maalouf, Karine Angioi, Jean-Luc George; Complications after Dacryoadenitis : about 9 cases. Invest. Ophthalmol. Vis. Sci. 2012;53(14):640.
  3. 3.0 3.1 Andrew NH, Kearney D, Sladden N, McKelvie P, Wu A, Sun MT, McNab A, Selva D. Idiopathic Dacryoadenitis: Clinical Features, Histopathology, and Treatment Outcomes. Am J Ophthalmol. 2016 Mar;163:148-153.e1. doi: 10.1016/j.ajo.2015.11.032. Epub 2015 Dec 15. PMID: 26701269.