Interesting Case Rounds

06.09.2007Nadim J Lalani PGY 4

?

"Pinkeye" (seventh South Park episode aired October 29, 1997).

• Mir space station crashes into (and kills) Kenny at a bus stop October 30.

• Kenny is taken to morgue• accidentally embalmed with fluid containing

Worcestershire sauce turns Kenny into a zombie. • Kenny breaks out of the morgue bites two coroners.• The morgue workers on exam:

– temp 55°F, pulseless, eyes are puffy and sticky.

• Doctor makes Dx : “pinkeye”. • Morgue workers turn into zombies spawn a zombie

epidemic• Culminates in characters dancing to “thriller” at the end

Case

• 23 m.o boy presented to PLC • c/o L eye swelling, erythema & pain.• Doctor?

• Hpi:Hx of rhinorrhea, fever and

conjunctival injection and R eye swelling 6 days ago.

Was rubbing eye. Saw FP 4 days ago who prescribed a topical ABx.

R eye got better, but then L eye became swollen, red and tender

• ROS: Fever 39.4 Mid-week. Hx finger poke to eye 1/12 ago. Nil else

• PmHx: normal/healthy pregnancy. Normal vag delivery. No hospitalisations.

• Immunisations: UTD

• What will you look for?

• Red Flags?

Physical Exam

• Vitals/general appearance:37.2 , HR 110 , RR 24 , 98% Flushed cheeks, but looks well• H&N:

L eyelid swollen and somewhat tenderNo skin break/No proptosis/Nochemosis/ No conjunctivitisNormal red reflexes/PEARL/ N eye mov’t

Physical Exam

• H&N cont’d: Normal TM’s/ Oropharynx clear/

No Lymph N’s

• Rest of exam: N

Ddx?• Infection

– Periorbital / orbital– Conjunctivitis – herpes or varicella – Hordeolum – Chalazion – Dacrocystitis

• Inflammation (blepharitis)• Allergies• Insect Bites• Trauma• Other: Tumors, Posterior scleritis , Periocular dermoid

cyst ,Wegener's granulomatosis of the orbit, Orbital pseudotumor.

Anatomy:

orbital septum Extends from the periosteum.

Fibrous sheath highly impermeable to infection.

Sinuses:

• Orbit shares a common wall with three sinuses:frontal sinusethmoid sinusmaxillary sinus.

• Sinuses line 2/3 of the orbit.• Infections from contiguous spread. • ethmoid sinus is the usual culprit.• Why?

– Has paper-thin wall [the lamina papyracea].

Classification

• Classically: Five categoriesI Preseptal cellulitis II Orbital cellulitisIII Subperiosteal abscess IV Orbital AbscessV Cavernous Sinus thrombosis

What’s wrong with this?

Chandler JR et.al. The Pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970; 80: 1414-1428

Preorbital (preseptal) cellulitis:

• More common than orbital cellulitis.• begins anteriorly get spread to eye lids. • Etiology:Conjunctivitis Chalazion, hordeolum Allergic reaction Local infection/trauma eg insect bites,

puncture wounds (cat bites e.g.)Dacryocystitis conditions such as erysipelas or impetigo. Rarely bacteremia

Lawless M and F Martin. ORBITAL CELLULITIS AND PRESEPTAL CELLULITIS IN CHILDHOOD. Australian and New Zealand Journal of Ophthalmology 1986; 14: 211-219

• Chart Review of 108 cases in Sydney (preseptal orbital abscess)

• Cited predisposing factors as:

URTI (coryza, pharingitis, injected TM’s, nasal congestion)

Trauma (lacs, blunt injuries, animal bites/scratches)

Pimples, styes, chalazia

Dacrocystitis

other infections (herpes simplex/ varicella)

Preorbital (preseptal) cellulitis:

• Clinically: no significant fever no leukocytosis symptoms are localized to the lids

and conjunctiva. no pain on eye movement and

vision is not impaired. there is no evidence of sinusitis on

plain film or CT.

Chalazia

Pre orbital cellulitis 20 to chalazion

Allergic reaction

Herpes blepharitis

Preorbital cellulits secondary to dacrocystitis

Preorbital (preseptal) cellulitis:

• Treatment:Oral antibiotics that cover skin flora.

amoxicillin-clavulanate first-generation cephalosporin.

7-10 days (Uptodate)Treatment failure in 24-48h warrants

further w/u.

Etiology, Diagnosis, and Treatment of Orbital InfectionsGary Schwartz, MD Curr Infect Dis Rep. 2002 Jun;4(3):201-205.

Orbital Cellulitis:

• Less common than preorbital• Pre antibiotic era mortality 20-50%• Mean age:

kids 3 - 14 yearsadults 30

• Purported seasonality (winter months)

Orbital Cellulitis:

• Etiology:60-90 % related to sinusitis (mostly

Ethmoid)Following URTI’sDental infections / surgeryerysipelas, impetigo, dacrocystitisTraumaMore rarely bacteremia from

endocarditis e.g

Clinical features:• Classically:High feverOrbital painLimited extraoccular motionDecreased visionProptosisIncreased WBC/ESR. Positive Blood

CultureNelson Essentials of Pediatrics 4th Edition. Behrman RE and Kliegman RM. Eds. 2002. Wb Saunders and Co. Pennsylvania USA

• Retrospective review of 49 patients with dx orbital cellulitis.

• Average age 30. • Symptom course 28 pts (57%) less than 7

days, 1-4 weeks in 17 (34%)• ALL had eyelid swelling• ALL had Chemosis• 45 (91%) had reduced occular movement• 46 (94%) had displaced eye (proptosis vs

downward vs lateral displacement)

Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986; 70 174-178.

Clinical features cont’d:

• Only 16 (32%) had a fever.• 23 (47%) had reduced visual acuity.• 9 (27%) had an increased WBC• 16 (32%) had ESR > 15 mm/h• 30 (61%) had AbN sinus x-ray

Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986; 70 174-178.

Eustis ES. et al. Staging of orbital Cellulitis in Children: Computerised Tomography Characteristics and treatment Guidelines. Journal of Pediatric Ophthalmology and Strabismus. Sept/Oct 1986, Vol 23 No 5: 246-251

•Retrospective review of 257 cases of periorbital and orbital (22) cellulitis at Sick Kids In Toronto

• Orbital clinically:

10 in Stage II (no decreased VA but 5 proptosis and 4 abn eye Mov’t, 3 had normal eye exam)

10 in Stage III ( 2 had decreased VA, 6 proptosis, 8 also had Abn eye mov’t)

1 in Stage IV (had abn VA, proptosis and Abn eye mov’t)

1 in Stage V

•Sinusitis in 100%

Blood cultures only positive in 1 pt

Towbin, R et.al. Postseptal Cellulitis: CT in Diagnosis and Management. Radiology. 1986; 158: 735-737

•Retrospective review of 12 cases in Cincinnati

• 9 (75%) had proptosis on admition. The other 3 developed it later.

• 11 (91%) had Abn eye movement

• 6 (50%) had painful eye mov’t

• 4 (33%) had diplopia

• 2 (16%) had decreased VA

• 2 (16%) had Chemosis

Hirsch M and T Lifshitz. Computerised tomography in the diagnosis and treatment of orbital cellulitis. Pediatric Radiology. 1988; 18: 302-305

•Retrospective Review 9 cases

•Mean age 9

• 8 had proptosis

• 8 had partial/total opthalmoplegia or gaze defect

• 2 had decreased VA

• 2 positive cultures (staph)

Summary:• Early stages pt may only present

with swelling and induration confined lids

• It is difficult to differentiate early orbital from periorbital cellulitis.

• Absence of predisposing factor should raise your suspicion.

Summary cont’d:

• RED FLAGS:– Proptosis / displaced eye– extraoccular muscle restriction– pain on eye movement,– chemosis – changes in visual acuity are – [NB: likely later signs].

• Tip: look for a “line of demarcation”

If clinical exam not always reliable, What About imaging?

• Plain Radiographs look for sinusitis:

• Various Studies • radiography sensitivities 60 - 90% range (Spec also 60 -90% range)

Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986; 70 174-178.

“Sinus x-rays are an integral part of the evaluation of orbital disease”

Xray Summary

• Can help in Dx, but not sensitive enough

What about U/S?

•   Retrospective review 17 patients (aged 1 to 10 years; mean age 4.5 years

• U/S performed either immediately or within 12 hr after admission.

• Orbital cellulitis excluded in 9 pts• 8 patients orbital cellulitis diagnosed,

– six had subperiosteal abscess – two had inflammation without abscess.

• Conclude: “We recommend orbital sonography in every child with periorbital swelling and erythema”.

• U/S Limitations can’t image sinuses or calvarium

Mair MH; Geley T; Judmaier W; Gassner I Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids in pediatric patients. Am J Roentgenol. 2002 Dec;179(6):1529-34.

• Who gets a CT?

CT:

Towbin, R et.al. Postseptal Cellulitis: CT in Diagnosis and Management. Radiology. 1986; 158: 735-737

Came up with a protocol:

Kids with CNS manifestations / “Surgery Imminent” / Dx difficulty get scanned

Everyone else gets trial Abx for 36-48 hours.

If the Abx fail to improve symptoms then the get scanned.

CT:Hirsch M and T Lifshitz. Computerised

tomography in the diagnosis and treatment of orbital cellulitis. Pediatric Radiology. 1988; 18: 302-305

Scan everybody so that one can stage the cellulitis

I -II can be treated conservatively

III and up go to the OR

CT:

Noel LP et.al. Clinical Management of Orbital Cellulitis in Children. Canadian Journal of Ophthalmology. 1990; 25 (1): 11-16

Most can be managed with Abx for 48h

Requires constant monitoring of patient

Failure of therapy buys a scan

CT:

Most can be managed with aggressive Abx

Failure of therapy buys a scan (no comment on how long to trial abx)

Indications for surgery are failure to improve on Abx, presence of foreign body, subperiosteal (stage III), Orbital abscess (stage IV)

Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986; 70 174-178.

CT:

CT for Visual Acuity decrease, proptosis, limitation of eye mov’t or uncertain of diagnosis

Failure of therapy buys a scan (no comment on how long to trial abx)

Indications for surgery are stage III (and presumably stage IV and V) . However “mild” stage III can be managed conservatively

Eustis ES. et al. Staging of orbital Cellulitis in Children: Computerised Tomography Characteristics and treatment Guidelines. Journal of Pediatric Ophthalmology and Strabismus. Sept/Oct 1986, Vol 23 No 5: 246-251

CT Summary:

Indications for CT scanning:• Inability to accurately assess vision • Gross proptosis, ophthalmoplegia, bilateral

edema, or deteriorating visual acuity • No improvement despite 24 hours of

intravenous antibiotics • Signs or symptoms of central nervous

system involvement • Going to OR

Antibiotics:• Suspected orbital cellulitis admit the patient and begin aggressive

Rx.• Empiric therapy should be directed against:

Gram Positives:Streptococcus species: Streptococcus pneumoniae, Streptococcus viridans Staphylococcus aureus and epidermis

Gram Negs:Moraxella catarrhalis (Haemophilus influenzae decreasing cause due to immunisations)

In adults: Also anaerobes  Bacteroides species  Veillonella parvula  Peptostreptococcus species  Fusobacterium species  

3rd Gen Cephalosporin IV or Amoxilin/sulbactamCourse should be IV until resolution but 14 d total

Sandford 2005

References:

Varonen H, Makela M, Savolainen S, Laara E, Hilden J, Comparison of ultrasound, radiography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systematic review. Journal of Clinical Epidemiology, 2000, 53(9), 940-948

Ros SP. Herman BE. Azar-Kia B. Acute sinusitis in children: is the Water's view sufficient? Pediatric Radiology. 25(4):306-7, 1995.

Jain A and PA Rubin. Orbital Cellulitis in Children. Int Ophthalmol Clin. 2001 Fall;41(4):71-86.

• David G Hunter,Michele Trucksis. Preseptal (periorbital) and orbital cellulitis Uptodateonline.

Givner, Laurence B. M.D. Periorbital versus orbital cellulitis. Canadian Journal of Ophthalmology. 1990 Feb;25(1):11-6.