What is the differential diagnosis for an 11-week-old child with a red, swollen eyelid and drainage?

Differential Diagnosis for Red Swollen Eyelid with Drainage in an 11-Week-Old

In an 11-week-old infant with red, swollen eyelid and drainage, the differential diagnosis must prioritize life-threatening conditions first: gonococcal and chlamydial conjunctivitis are emergencies requiring immediate systemic antibiotics, followed by bacterial conjunctivitis (most commonly Staphylococcus aureus at this age), nasolacrimal duct obstruction with acute dacryocystitis, preseptal cellulitis, and herpes simplex virus conjunctivitis. 1, 2, 3

Life-Threatening Conditions (Rule Out First)

Gonococcal Conjunctivitis

• Any purulent conjunctivitis in a neonate is an emergency until gonococcal causes are ruled out, as this can cause corneal perforation within 24-48 hours, septicemia, meningitis, and death 1, 3
• Presents with severe, rapidly reaccumulating purulent discharge and marked eyelid swelling 1
• Requires immediate conjunctival swab for Gram stain and culture; if Gram-negative diplococci are present, treat immediately with systemic antibiotics before culture confirmation 3
• Always examine the cornea with fluorescein staining to detect early corneal involvement 1

Chlamydial Conjunctivitis

• Presents with follicular conjunctivitis, though follicles may be less prominent in very young infants 1
• Requires systemic antibiotics (oral therapy), not just topical treatment 1, 3
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1

Herpes Simplex Virus Conjunctivitis

• The presence of eyelid vesicles is pathognomonic and requires immediate ophthalmology referral 4
• Can progress to keratitis, stromal keratitis, corneal scarring, perforation, uveitis, and retinitis 1
• Requires antiviral therapy, not antibiotics 4

Common Bacterial Causes in This Age Group

Bacterial Conjunctivitis (Non-Gonococcal)

• In the neonatal period and early infancy, Staphylococcus aureus is the most common bacterial cause, followed by Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis 5
• Presents with purulent or mucopurulent discharge, matted eyelids, and conjunctival injection 6, 5
• Topical antibiotic therapy should be started immediately for presumed bacterial conjunctivitis with mucous discharge and eyelid swelling 4
• Fluorescein staining is mandatory to detect corneal involvement 4

Structural/Anatomical Causes

Nasolacrimal Duct Obstruction with Acute Dacryocystitis

• Nasolacrimal duct obstruction is the most common cause of persistent tearing in children younger than 1 year 2
• When complicated by acute dacryocystitis, presents with erythema, swelling, warmth, and tenderness over the lacrimal sac (medial canthal area) 2
• Acute dacryocystitis requires urgent ophthalmology referral due to high risk of complications including periorbital and orbital cellulitis, meningitis, brain abscess, and sepsis 2
• Dacryocystoceles present with bluish discoloration over the nasolacrimal sac and also require urgent ophthalmology referral 2

Serious Orbital Complications

Preseptal (Periorbital) Cellulitis

• Presents with eyelid swelling, erythema, and warmth, but without proptosis or impaired extraocular muscle function 7
• In children younger than 5 years, often secondary to ethmoid sinusitis 7
• Eye swelling is attributable to impedance of venous drainage secondary to congestion within the ethmoid sinuses 7
• If accompanied by proptosis or impaired extraocular muscle function, obtain contrast-enhanced CT scan immediately to rule out orbital cellulitis, subperiosteal abscess, or orbital abscess 7

Viral Causes (Less Likely with Purulent Drainage)

Adenoviral Conjunctivitis

• Typically presents with watery to serofibrinous discharge, not purulent drainage 1, 6
• Bilateral presentation (though may start unilaterally), periauricular lymphadenopathy 1
• Self-limited, resolving within 5-14 days with supportive care 1

Critical Red Flags Requiring Immediate Ophthalmology Referral

• Severe or rapidly reaccumulating purulent discharge 4
• Corneal involvement detected on fluorescein examination 4
• Eyelid vesicles or rash suggesting HSV 4
• Proptosis or impaired extraocular muscle function 7
• Bluish discoloration over lacrimal sac (dacryocystocele) 2
• No improvement after 3-4 days of appropriate antibiotic treatment 4

Diagnostic Approach Algorithm

1. Immediately assess for life-threatening conditions: Obtain conjunctival swab for Gram stain and culture in any infant with purulent discharge 3
2. Perform fluorescein staining to detect corneal involvement 1, 4
3. Examine for eyelid vesicles (HSV) and assess extraocular movements and proptosis (orbital complications) 7, 4
4. Palpate over lacrimal sac for warmth, tenderness, or bluish mass 2
5. If Gram-negative diplococci present or severe purulent discharge: Treat immediately for gonococcal infection with systemic antibiotics 3
6. If eyelid vesicles present: Urgent ophthalmology referral for HSV 4
7. If proptosis or impaired extraocular movements: Obtain contrast-enhanced CT scan for orbital complications 7
8. If dacryocystitis or dacryocystocele suspected: Urgent ophthalmology referral 2
9. If uncomplicated bacterial conjunctivitis: Start topical antibiotics and follow up in 3-4 days 4, 5