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Case Study: October 2010
History
- Woman aged 66
- Recurrent dacryocystitis involving left upper lid for 6 months. Cultures negative.
- Developed ‘’papillomatous’’ lesion left upper canaliculus
- Excised
- See Figures
Questions
- What is the diagnosis?
- What do the figures show?
- What is the infectious agent ?
- Why were cultures negative?
- What is the recommended treatment?
Click to show answers
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- Dacryolithiasis and actinomyces infection with chronic conjunctivitis and dacryocystitis.
- Biopsy shows chronically inflamed conjunctiva with lymphoid aggregates (Figs 1 & 2) . A ‘’stone’’ is present (Fig 3). Fig 4 shows radiating filamentous arrangement of organisms and inflammatory exudate around ‘’stone’’. Gram stain (Fig 5) shows Gram positive filamentous organisms.
- The agent is Actinomyces spp. (Usually A. israelii).
- Cultures were negative as they were taken from the surface conjunctiva. The organisms lay deep within the canaliculus.
- The recommended treatment is curettage of the calculus and canaliculotomy. Topical antibiotics are rarely effective.
Dacryoliths are often found as an underlying factor causing obstruction in chronic dacryocystitis and may be seen on CT imaging. Actinomyces may cause secondary conjunctivitis.
References
CT Demonstration of Dacryolithiasis Complicated by Dacryocystitis Asheim J, Spickler E. American Journal of Neuroradiology 2005;26:2640-1
Actinomyces canaliculitis; diagnosis of a masquerading disease. Briscoe D, Edelstein E,Zacharopoulus I, Keness Y, Kilman A, Zur F, Assia El. Graefes Arch Clin Exp Ophthalmol 2004;242 (8):682-6
Lacrimal excretory system concretions: canalicular and lacrimal sac Repp DJ, Lucarelli MJ. Ophthalmology 2009;116 (11) :2230-5
