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• W1918960203 abstract "A 49-year-old HIV-infected man (category B2) was admitted to our hospital with periorbital swelling, fever and malaise. Six days before admittance he suffered mild left eyebrow trauma. Three days later he developed palpebral swelling and ocular pain and was transferred to the emergency room of our hospital, where he was diagnosed as having preseptal cellulitis with a normal paranasal sinus X-ray film. Treatment with oral amoxycillin–clavulanate was prescribed. The eyebrow wound was sutured but no visual evaluation was performed because the patient could not open the eye. He returned to the emergency room due to worsening of his condition. Clinical examination revealed severe ocular pain associated with chemosis, proptosis, amaurosis and periorbital swelling (Figure 1). A head CT scan was performed (Figure 2).Figure 2CT of the patient on admission.View Large Image Figure ViewerDownload (PPT) 1What is your clinical diagnosis?2What is the most common etiology of this syndrome?3What is the most probable microorganism in this patient?4What would be your therapeutic approach? The clinical diagnosis was orbital cellulitis (without abscess formation) and myositis, associated with anterior displacement of the ocular globe. Orbital cellulitis, also known as postseptal cellulitis, is an acute infection of the orbital contents. It is a serious infection because of the risk of visual loss and posterior spread affecting the cavernous sinus. This infection is mostly caused by bacteria, and Staphylococcus aureus, Streptococcus pyogenes and Streptococcus pneumoniae are the most common. Haemophilus influenzae was the predominant pathogen until the introduction of extensive vaccination in the mid-1980s. In patients with underlying diseases, fungi can also be a cause. The most common predisposing factors are sinusitis, preseptal cellulitis and hematogenous spread. These mainly affect children between 4 and 9years of age, whereas in adults trauma, puncture wounds and surgery are more frequently reported [1Noel LP Clarke WN Peacocke TA Periorbital and orbital cellulitis in childhood.Can J Ophthalmol. 1981; 16: 178-180PubMed Google Scholar, 2Weiss A Friendly D Eglin K Chang M Gold B Bacterial periorbital and orbital cellulitis in childhood.Ophthalmology. 1983; 90: 195-203Abstract Full Text PDF PubMed Scopus (115) Google Scholar, 3Ricos Furio G Gibert Agullo A Youssef Fasheh W Etmoiditis aguda. Revisiã³n de 38 casos.An Esp Pediatr. 1996; 44: 129-132PubMed Google Scholar, 4Donahue SP Schwartz G Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum.Ophthalmology. 1998; 105: 1902-1906Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 5Brook I Friedman EM Rodriguez WJ Controni G Complications of sinusitis in children.Pediatrics. 1980; 66: 568-572PubMed Google Scholar]. In the case reported here, the Gram stain of purulent material aspirated from the eyebrow showed Gram-positive cocci in chains. A rapid antigenic test for Streptococcus pyogenes performed on the purulent exudate was also positive. Cultures grew Streptococcus pyogenes. Neither mycobacteria, fungi nor other bacterial pathogens were isolated in cultures from the exudate. Treatment of bacterial orbital cellulitis relies on prompt administration of intravenous antibiotics and surgical evaluation. Empirical therapy could be based on a third-generation cephalosporin (cefotaxime or ceftriaxone) with or without cloxacillin, or amoxycillin–clavulanate, until culture and susceptibility results are available. If resistance is suspected or the patient is allergic, vancomycin may be used. Surgical therapy is preferred in cases of orbital abscess. Surgery is not indicated if there is no identifiable purulent collection (except in severe sepsis which does not respond to medical therapy alone) or in the case of a subperiosteal abscess that seems to be responding to conservative measures [1Noel LP Clarke WN Peacocke TA Periorbital and orbital cellulitis in childhood.Can J Ophthalmol. 1981; 16: 178-180PubMed Google Scholar, 2Weiss A Friendly D Eglin K Chang M Gold B Bacterial periorbital and orbital cellulitis in childhood.Ophthalmology. 1983; 90: 195-203Abstract Full Text PDF PubMed Scopus (115) Google Scholar, 3Ricos Furio G Gibert Agullo A Youssef Fasheh W Etmoiditis aguda. Revisiã³n de 38 casos.An Esp Pediatr. 1996; 44: 129-132PubMed Google Scholar, 4Donahue SP Schwartz G Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum.Ophthalmology. 1998; 105: 1902-1906Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 5Brook I Friedman EM Rodriguez WJ Controni G Complications of sinusitis in children.Pediatrics. 1980; 66: 568-572PubMed Google Scholar]. Surgical treatment consists of external drainage, although in cases of subperiosteal abscess, endoscopy is an alternative [6Page EL Wiatrak BJ Endoscopic vs external drainage of orbital subperiosteal abscess.Arch Otolaryngol Head Neck Surg. 1996; 122: 737-740Crossref PubMed Scopus (36) Google Scholar]. Orbital cellulitis caused by Streptococcus pyogenes has some particular characteristics. It affects middle-aged persons with alcoholism or diabetes as common underlying diseases and trauma as portal of entry. Infection progresses rapidly, producing eyelid necrosis and, frequently, permanent visual loss caused by ophthalmic artery occlusions and/or optic nerve straightening (excessive elongation). Common complications include renal and respiratory failure, mental status deterioration and septic shock [7Shayegani A MacFarlane D Kazim M Grossman ME Streptococcal gangrene of the eyelids and orbit.Am J Ophthalmol. 1995; 120: 784-792Abstract Full Text PDF PubMed Scopus (37) Google Scholar, 8Ingraham HJ Ryan ME Burns JT et al.Streptococcal preseptal cellulitis complicated by the toxic Streptococcus syndrome.Ophthalmology. 1995; 102: 1223-1226Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 9Pannier M Bouchot-Hermouet M Lavergne-Hepner D Hepner Y David A Stalder JF Beta-hemolytic streptococcal periorbital necrotizing fasciitis in a child.Ann Chir Plast Esthet. 1991; 36: 75-78PubMed Google Scholar]. Penicillin is the drug of choice for Streptococcus pyogenes but clindamycin may be better in cases of extensive muscle involvement [10Eagle H Experimental approach to the problem of treatment failure with penicillin. I. Group A streptococcal infection in mice.Am J Med. 1952; 13: 389-399Abstract Full Text PDF PubMed Scopus (194) Google Scholar,11Stevens DL Gibbons AE Bergstrom R Winn V The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis.J Infect Dis. 1988; 158: 23-28Crossref PubMed Scopus (415) Google Scholar]. The use of normal pooled human immunoglobulins in cases of severe sepsis is promising [12Takei S Arora YK Walker SM Intravenous immunoglobulin contains specific antibodies inhibitory to activation of T cells by staphylococcal toxin superantigens.J Clin Invest. 1993; 91: 602-607Crossref PubMed Scopus (294) Google Scholar,13Barry W Hudgins L Donta ST Pesanti EL Intravenous immunoglobulin therapy for toxic shock syndrome.JAMA. 1992; 267: 3315-3316Crossref PubMed Scopus (205) Google Scholar]. Surgery is mandatory if there is abscess formation or if the patient is not responding to medical therapy alone. In cases of increased intraorbital pressure, the optic nerve may be damaged, leading to visual loss in a few hours. Lateral cantholysis may decompress the orbit but may also result in increased anterior globe displacement. Therefore, rapid posterior orbital decompression may be considered if tenting of the globe is detected [7Shayegani A MacFarlane D Kazim M Grossman ME Streptococcal gangrene of the eyelids and orbit.Am J Ophthalmol. 1995; 120: 784-792Abstract Full Text PDF PubMed Scopus (37) Google Scholar]." @default.
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• W1918960203 title "Diagnosis at first glance: periorbital swelling and visual loss in an HIV-infected patient" @default.
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