Recurrent Emesis and Respiratory Distress in a Full-Term Newborn

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ESPR450
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History: Female infant was born via normal spontaneous vaginal delivery following an uncomplicated pregnancy with negative serologies. Delivery complicated by fetal tachycardia and chorioamnionitis, for which mother was treated with ampicillin and gentamicin prior to delivery. Apgar scores were 8 and 8. Infant received 7 days of ampicillin and gentamicin; blood cultures were negative. Infant with recurrent non-bloody, non-bilious emesis and intermittent sustained desaturations, most notable to a low of 38% on room air on day of life (DOL) 3, requiring both stimulation and brief CPAP administration. Some desaturation events were associated with choking and emesis. Family history was notable for father with history of intussusception in infancy and maternal grandfather with gastroesophageal reflux disease (GERD), secondary to congenital Schaztki ring diagnosed in childhood.

Physical Exam: Patient was afebrile and other vital signs were unremarkable. She was well-appearing, without obvious facial deformities/asymmetry. Lungs were clear to auscultation without tachypnea or retractions. Heart sounds were normal, with no murmur. Her abdomen was soft and non-distended, with appropriate tone and responsiveness for age. During the desaturation episode to 38%, the patient was found to be hypopneic and grey in color. 


Laboratory testing and/or diagnostic imaging: Patient's initial laboratory work up was significant for an unremarkable BMP and mildly elevated WBC count (31.1x10^9/L), immature/total neutrophil ratio (0.2), and C-reactive protein level (1.15 mg/dL). These abnormal values were trended, and quickly returned to normal ranges. Patient had an unremarkable chest and abdominal radiograph, abdominal ultrasound, head ultrasound and echocardiogram. Fluoroscopic upper gastrointestinal (UGI) series demonstrated delayed gastric emptying without evidence of malrotation. Nasal endoscopy and MRI were performed, which revealed the diagnosis. 


Final Diagnosis: Dacrocystocele with nasolacrimal duct obstruction. Nasal endoscopy revealed a right cystic mass in the inferior meatus that was crowding the majority of the nasal cavity, suspicious for a nasolacrimal duct cyst (Image 1). Magnetic resonance imaging of the orbits demonstrated findings consistent with right dacryocystocele and dilated nasolacrimal duct extending past the inferior meatus, most consistent with nasolacrimal duct obstruction (Image 2).


Discussion: This case describes a full term female who presented with intermittent emesis and respiratory distress, found to have a large, obstructive right dacryocystocele, with complete resolution of symptoms after marsupialization by ENT in the OR. Dacryocystoceles are a rare cause of neonatal respiratory distress, usually secondary to nasal obstruction in obligate nasal breathing neonates. In this case, the unilateral obstruction was likely exacerbated by recurrent emesis, perhaps secondary to delayed gastric emptying, resulting in the recurrent episodes of desaturations.

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NYP Weill Cornell Medical Center
NYP Weill Cornell Medical Center
NYP Weill Cornell Medical Center

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