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C aseC ase

HPI, continued:HPI, continued:Has not h ad fever, no known trauma, no known insectHas not h ad fever, no known trauma, no known insectbites.bites.

No recent ill contacts.No recent ill contacts.Past Medical History:Past Medical History:

Hospitalized 4 mont h s prior to admission wit h RSV+Hospitalized 4 mont h s prior to admission wit h RSV+bronc h iolitisbronc h iolitis

Past Surgical History:Past Surgical History:NoneNone Allergies Allergies

NKDANKDA

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C aseC ase

ImmunizationsImmunizationsUp to dateUp to date

MedicationsMedicationsNo daily medicationsNo daily medications

DietDietNormal toddler dietNormal toddler diet

Family h istoryFamily h istoryParents, siblings h ealt h y. No family h istory of skin or Parents, siblings h ealt h y. No family h istory of skin or soft tissue infections.soft tissue infections.

Social h istorySocial h istoryLives in SL C with parents, siblings. Attends daycare.Lives in SL C with parents, siblings. Attends daycare.

No recent travel. Parents smoke outside t h e h ome.No recent travel. Parents smoke outside t h e h ome.

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C aseC ase

P h ysical examination:P h ysical examination:T 36.8. HR 144. RR 40. BP 117/80T 36.8. HR 144. RR 40. BP 117/80WT 14 kg (98%) HT 89cm (99%)WT 14 kg (98%) HT 89cm (99%)Gen: crying wit h exam but consoles, appears to be inGen: crying wit h exam but consoles, appears to be inpainpainHead:Head: Normocep h alicNormocep h alicEyes: Rig h t eye wit h 6cmx4cm area of Eyes: Rig h t eye wit h 6cmx4cm area of eryt h emaeryt h ema, ,significant edema wit h significant edema wit h proptosisproptosis. Purulent drainage. Purulent drainagefrom eye. Eye is swollen s h ut. C onjunctiva arefrom eye. Eye is swollen s h ut. C onjunctiva areinjected wit h mild edema. PERRL. Unable toinjected wit h mild edema. PERRL. Unable tocompletely assess EOM or visual acuity. Left eye iscompletely assess EOM or visual acuity. Left eye isnormalnormal

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C aseC ase

P h ysical examination, continued:P h ysical examination, continued:Ears: TMs normal bilaterallyEars: TMs normal bilaterallyNose: no disc h argeNose: no disc h argeMout h : orop h arynx is clear Mout h : orop h arynx is clear Neck: non tender, normal ROMNeck: non tender, normal ROMC V: tac h ycardic, no murmur auscultated, palpableC V: tac h ycardic, no murmur auscultated, palpablepulses, cap refill 3 secondspulses, cap refill 3 secondsLungs: C TAB, normal work of breat h ingLungs: C TAB, normal work of breat h ing

Abdomen: soft, no HSM, non distended Abdomen: soft, no HSM, non distendedSkin: no ras h Skin: no ras h

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DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISIDID

PreseptalPreseptal cellulitiscellulitisOrbitalOrbital cellulitiscellulitisHerpes simplex viralHerpes simplex viral

infectioninfectionMeibobianMeibobian gland abscessgland abscess

ON CON CRetinoblastomaRetinoblastomaLeukemiaLeukemia

Rh abdomyosarcomaRh abdomyosarcomaBurkittBurkitt lymp h omalymp h oma

Rh eumRh eumWegener Wegener granulomatosisgranulomatosisSarcoidosisSarcoidosis

OrbitalOrbital pseudotumor pseudotumor

TraumaTraumaForeign BodyForeign Body

Allergic response Allergic responseHypoproteinemiaHypoproteinemiaSubperiostealSubperiosteal h ematoma,h ematoma,

orbital wall infarction (sickleorbital wall infarction (sicklecell)cell)

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Laboratory Data:Laboratory Data:C BC : WB C 15 (43% neutrop h ils, 0% bands, 44%C BC : WB C 15 (43% neutrop h ils, 0% bands, 44%lymp h ocytes) Hct 37.1, Plts 271,000lymp h ocytes) Hct 37.1, Plts 271,000C RP 3.2C RP 3.2

MicroMicroBlood culture: no growt hBlood culture: no growt hRoutine culture of eye disc h arge:Routine culture of eye disc h arge:

Result: Stap h ylococcus aureus met h icillin resistant,mecAResult: Stap h ylococcus aureus met h icillin resistant,mecAgene detected.gene detected.S: clindamycin, eryt h romycin base, tetracycline, trimet h /sulfa,S: clindamycin, eryt h romycin base, tetracycline, trimet h /sulfa,vancomycinvancomycinR: oxacillin, penicillinR: oxacillin, penicillin

Routine culture abscess fluid: MRSARoutine culture abscess fluid: MRSA

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C T ImageC T ImageRig h t lateral orbitalRig h t lateral orbital p h legmonph legmon/abscess centered/abscess centeredwith in t h ewith in t h e preseptalpreseptal space wit h minimalspace wit h minimalpostseptalpostseptal/ /extraconalextraconal extension. T h e rimextension. T h e rim--en h ancingen h ancingph legmonph legmon/abscess measures up to 2.2 x 1.2 x 1.2 cm/abscess measures up to 2.2 x 1.2 x 1.2 cmand t h ere is extensive surroundingand t h ere is extensive surrounding cellulitiscellulitis. No. Noradiopaqueradiopaque foreign body is seen.foreign body is seen.

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DIAGNOSISDIAGNOSIS

MRSAMRSA PeriorbitalPeriorbital cellulitiscellulitis and abscessand abscesswith orbital extensionwith orbital extension

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Definitions:Definitions:Orbital cellulitis (postseptal cellulitis) islocalized posterior to t h e orbital septum, andinvolves infection of t h e fat and musclecontained wit h in t h e bony orbitPreseptal cellulitis (periorbital cellulitis), is a

soft tissue infection localized anterior to th

eorbital septum

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PreseptalPreseptal OrbitalOrbital

FrequencyFrequency More commonMore common(3x)(3x)

RareRare

SeveritySeverity Mortality andMortality and

vision loss rarevision loss rare

11--2% mortality, 32% mortality, 3- -

11% vision loss11% vision loss

PresentationPresentation Eye swelling,eryt h ema.

--ProptosisProptosis--Limitation of eyeLimitation of eyemovementmovement

--Double vision or Double vision or vision lossvision loss

PredisposingPredisposingfactorsfactors

Dacrocystitis, sinusitis/Dacrocystitis, sinusitis/URI, Infection after URI, Infection after trauma, insect or animaltrauma, insect or animal

bitebite

SINUSITIS,SINUSITIS,dacrocystitis, foreigndacrocystitis, foreignbody, surgery, facebody, surgery, face

infectioninfection

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MicrobiologyMicrobiology

PreseptalPreseptal: :Stap h ylococcus aureus, Stap h epidermitis,Strep pyogenes 75%Streptococcus pneumoniae

Anaerobes

Orbital: Stap h aureus, strep speciesMRSA

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Indications for C TIndications for C T

Indications for C TIndications for C T1) eyelid edema t h at makes complete examination impossible1) eyelid edema t h at makes complete examination impossible2) presence of C NS involvement (suc h as focal neurologic deficits,2) presence of C NS involvement (suc h as focal neurologic deficits,seizure, or altered mental status)seizure, or altered mental status)3) deteriorating visual acuity or color vision, gross3) deteriorating visual acuity or color vision, gross proptosisproptosis, or , or op h th almoplegiaop h th almoplegia4) clinical deterioration or no improvement4) clinical deterioration or no improvement

Order: C ontrastOrder: C ontrast- -en h anced C T scanningen h anced C T scanningwith with sagittalsagittal, coronal, and axial slices of , coronal, and axial slices of th e orbit and sinusesth e orbit and sinuses

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Learning Point: D TestLearning Point: D TestTh ree classes of antibiotics work similarly

Macrolides (eryt h romycin), lincosamide (clindamycin),streptogramin BWork on t h e same site, so t h ere can be cross resistanceMLSb p h enotype-genetic makeup associated wit h cross

resistanceResistance results from modifying t h e binding siteEnzyme encoded by erm genes

Genetic expressionMLSbc (constitutive) or MLSbi (inducible)

If contitutive->resistance to all t h ree antibioticsInducible genotype->resistant to eryt h romycin, susceptibleto clinda

Eryt h romycin is Efficient inducer, clinda is poor

MLSbi can mutate to MLSBc

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C linical relevance

Postive D test means bacteria can developresistance to clinda during t h erapy

Serious infections with

positive D test->noclindamycin

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ReferencesReferences

Periorbital and Orbital cellultis. AndreaPeriorbital and Orbital cellultis. AndreaHauser and Simone Fogarasi. DOI:Hauser and Simone Fogarasi. DOI:10.1542/pir.3110.1542/pir.31- -66--242242 Pediatr. Rev.Pediatr. Rev.2010;31;242 2010;31;242- -249249

Th e D Test. Kamaks h ya Patra. Peds inTh e D Test. Kamaks h ya Patra. Peds inReview. July 2011Review. July 2011