What could cause blepharitis, nasal congestion, and cough persisting for several weeks?

Chronic Rhinovirus Infection with Secondary Blepharitis

The most likely cause of blepharitis, nasal congestion, and cough persisting for several weeks is a prolonged viral upper respiratory infection (most commonly rhinovirus) that has triggered secondary chronic blepharitis and upper airway inflammation. 1

Primary Pathophysiology

Viral upper respiratory infections, particularly rhinovirus, commonly present with the exact triad you describe:

• Nasal congestion and discharge are hallmark symptoms of rhinovirus infection 1
• Cough can persist for 10 days or longer in uncomplicated viral URI 1
• Symptoms may last more than 15 days in approximately 7-13% of cases 1

The blepharitis component develops through two mechanisms:

1. Direct viral-induced inflammation: The host inflammatory response releases interleukin-1, interleukin-6, interleukin-8, and tumor necrosis factor-α, which can affect the eyelid margins 1
2. Associated allergic conjunctivitis: Allergic rhinitis is often accompanied by symptoms of allergic conjunctivitis, which can manifest as eyelid inflammation 2

Diagnostic Approach

Look for these specific clinical features to confirm the diagnosis:

For Upper Airway Disease

• Clear to cloudy nasal discharge (white blood cells and desquamated epithelium cause cloudiness, not necessarily bacterial infection) 1
• Postnasal drip sensation with throat clearing 2
• Facial pressure without severe unilateral pain 1
• Absence of "double sickening" (initial improvement followed by deterioration) 1

For Blepharitis

• Bilateral eyelid margin erythema and crusting (hallmark finding) 3
• Symptoms worse in the morning 3
• Slit-lamp examination revealing debris along eyelid margins, telangiectasia, and meibomian gland abnormalities 3
• Foamy discharge on the eyelid margin 2

Critical red flags requiring immediate evaluation:

• Unilateral blepharitis with focal ulceration or nodular mass (consider sebaceous carcinoma) 3
• Severe unilateral facial pain with high fever (bacterial sinusitis) 1
• Symptoms worsening after 5-7 days or persisting beyond 10 days with deterioration (bacterial superinfection) 1

Treatment Algorithm

First-Line Management (Initiate Immediately)

For Blepharitis: 3

1. Eyelid hygiene as foundation of treatment:
   • Warm compresses to eyelid margins
   • Gentle eyelid cleansing with diluted baby shampoo or commercial lid scrubs
   • Gentle eyelid massage (avoid aggressive massage if glaucoma present) 3
2. Preservative-free artificial tears for symptomatic relief 3

For Upper Airway Symptoms: 2

1. Intranasal corticosteroids (e.g., fluticasone, mometasone) for 2-4 weeks for nasal congestion and postnasal drip 2
2. Second-generation oral antihistamines if allergic component suspected 2
3. Supportive care: hydration, humidification

Second-Line Management (If No Improvement After 2-3 Weeks)

For Blepharitis: 3

• Short-term topical corticosteroids for acute exacerbations with significant inflammation
• Must monitor intraocular pressure carefully within 2-3 weeks 3
• Consider topical antibiotics if bacterial colonization suspected (though evidence is limited) 4

For Persistent Upper Airway Symptoms: 2

• Trial of proton pump inhibitors (omeprazole 20-40 mg twice daily before meals for at least 8 weeks) if gastroesophageal reflux suspected as contributing factor 2
• Consider evaluation for underlying conditions: asthma, allergic rhinitis, chronic rhinosinusitis 2

Important Clinical Caveats

Do NOT prescribe antibiotics for this presentation unless:

• Symptoms worsen after 5-7 days 1
• Symptoms persist beyond 10 days with severe unilateral pain and high fever 1
• Purulent nasal discharge persists beyond 10-14 days (bacterial sinusitis) 2
• Bacterial superinfection occurs in less than 2% of viral URI cases 1

The blepharitis is chronic and recurrent: 3

• Educate patients that symptoms can frequently be improved but are rarely eliminated
• Long-term commitment to eyelid hygiene is essential 3, 5
• Symptoms typically worsen in the morning, distinguishing it from aqueous-deficient dry eye 3

Avoid aggressive eyelid massage in patients with advanced glaucoma as this can increase intraocular pressure 3

Follow-Up Schedule

• Re-evaluate within 2-3 weeks if moderate-severe blepharitis or if topical corticosteroids prescribed 3
• Assess treatment response, measure intraocular pressure, and check compliance 3
• Consider biopsy if blepharitis fails to respond to standard therapy within 2-4 weeks, especially if unilateral 3
• Viral URI symptoms should resolve within 7-10 days in most cases; persistence beyond 10 days warrants re-evaluation for bacterial superinfection 1