Senior Report 7.10

Case Presentation by Dr. Jessica Ruffino, MD

CC: Headache

HPI: Patient is 14y/o female who presents to the emergency department with her mother with the above complaint.   Patient states that she has been having headaches intermittently for the past 3 weeks, however her headache has been getting much worse over the past 3 days. She states that the pain is located on the left side of her forehead and behind her left eye. Describes the pain as throbbing and constant. Associated with photophobia, as well as nausea but no vomiting. Does note some neck pain. She thinks she may have a fever but has not checked her temperature. She noticed left eye swelling over past day, but today she can’t open her left eye. Denies any blurry vision or double vision, no discharge from eye. She states that she has been to several other emergency departments over past few weeks regarding her headache and was told she has migraines. She has tried taking ibuprofen with little relief. She states she has had a cold recently with nasal congestion. She denies any trauma, does not wear contacts and usually does not have headaches.

ROS:
Constitutional: Subjective fever
Eyes: Left eye swelling
Ears, Nose, Mouth, Throat: Nasal congestion
Musculoskeletal: Denies joint pain
Skin: Denies rash
Neurological: Headache

PMH: Asthma, no history of migraines

PSH: None

Immunizations: Up-to-date

Allergies: None

Medications: Albuterol

Social History: Denies alcohol, tobacco, or drug use. 8th grade student.

Physical Exam:
General: Patient is alert and oriented x 3. Laying on stretcher with lights off in room. Uncomfortable but she is cooperative.
Vital signs: Blood pressure 95/40, pulse 115, respiratory rate 16, temperature 39.2, pulse ox 99% on room air
Eyes: There is erythema, edema of left eyelid and periorbital edema of the left eye. Left eye proptosis present. Chemosis of left sclera. Pupils equal, round, and reactive to light.   Extraocular movements appear to be intact, however exam somewhat limited secondary to edema of left eye. There is pain with movement of left eye. Vision 20/20 bilaterally. Photophobia noted bilaterally.
Ears, Nose, Throat: Tympanic membranes are not red or bulging. No rhinorrhea. No erythema or exudates, no sinus tenderness, oral exam wnl
Neck: Supple, nontender, no meningismus
Cardiovascular: Tachycardic. Regular rhythm, S1 and S2 with no murmurs, gallops or rubs
Neurologic: Alert and oriented times 3. Cranial nerves II-XII appear to be intact, again with some limitation of assessing extraocular movements of left eye secondary to edema. Strength 5/5 bilateral upper and lower extremities.   Sensation to light touch intact throughout. No dysmetria or dysdiadochokinesia.

ruffinoj

 

 

 

 

 

 

Questions:

  1. Which of the following physical exam findings are indicative of orbital cellulitis, compared to preseptal cellulitis
    a)Chemosis
    b) Proptosis
    c)Opthalmoplegia
    d) All of the above
  2. Which of the following is seen in preseptal cellulitis?
    a) Subperiosteal abscess
    b) Vision loss
    c) Cavernous sinus thrombosis
    d) Periorbital edema and erythema
  3. What is the best choice for initial antibiotic regimen in treating orbital cellulitis?
    a) Vancomycin and Ampicillin-sulbactam
    b) Vancomycin and metronidazole
    c) Ceftriaxone
    d) Augmentin

    Answers & Discussion:

    1) D
    2) D
    3) A

    Orbital Cellulitis
    Orbital cellulitis is an infection involving the contents of the orbit including fat and ocular muscles. Preseptal cellulitis or periorbital cellulitis is infection of the anterior portion of the eyelid. Neither involves the globe itself.

    Sometimes preseptal and orbital cellulitis are difficult to distinguish clinically because both can cause ocular pain and eyelid swelling and erythema. It is important to distinguish the two as they have very different clinical implications. Preseptal cellulitis rarely leads to serious complications, whereas orbital cellulitis may cause vision loss and even death. Distinguishing clinical features of orbital cellulitis include ophthalmoplegia, pain with eye movements, and proptosis. Also diagnosed by imaging studies (CT and possibly MRI). If unsure if a patient has orbital versus preseptal cellulitis, treat the patient as if they have orbital cellulitis.   This would mean that this patient would need to be admitted for IV antibiotics. It is extremely important to carefully examine the patient for pain with eye movement. CT scan with contrast is used to make diagnosis. Axial views should include low, narrow cuts of the frontal lobes to rule out peridural and parenchymal brain abscess formation. Coronal views are helpful in determining the presence and extent of any subperiorbital abscesses. MRI may be helpful in defining orbital abscesses and in evaluating the possibility of cavernous sinus disease.

    Preseptal cellulitis is much more common than orbital cellulits. Both conditions are more common in children than in adults.

    Most common cause of orbital cellulitis is rhinosinusitis, with ethmoid and pansinusitis being most common locations. Ethmoid sinuses are separated from the orbit by the lamina papyracea, a thin structure with many fenestrations. Computed tomography (CT) scanning often shows the predominant site of inflammation to be the medial aspect of the orbit, adjacent to the ethmoid sinuses, and subperiosteal abscesses most often occur in the same. Other potential causes include ophthalmic surgery, orbital trauma with fracture or foreign body, dacryocystitis, infection of the teeth, middle ear, or face, infected mucocele that erodes into the orbit.

    1. D—all of the above

    Both orbital cellulitis and preseptal cellulitis cause ocular pain and eyelid swelling with erythema. In some cases of orbital cellulitis, eyelid erythema is absent. Only orbital cellulitis causes swelling and inflammation of the extraocular muscles and fatty tissues within the orbit, leading to pain with eye movements, proptosis, and ophthalmoplegia with diplopia. Chemosis may occasionally occur in severe cases of preseptal cellulitis, but is more common with orbital cellulitis.

    Clinical features of preseptal and orbital cellulitis

    Clinical Feature Preseptal Cellulitis Orbital Cellulitis
    Eyelid swelling with or without erythema Yes Yes
    Eye pain/tenderness May be present Yes; may cause deep eye pain
    Pain with eye movements No Yes
    Proptosis No Usually, but may be subtle
    Ophthalmoplegia +/- diplopia No Yes
    Vision impairment No May be present
    Chemosis Rarely present May be present
    Fever May be present Usually present
    Leukocytosis May be present May be present

     

    1. D— Periorbital edema and erythema

    Preseptal cellulits and orbital cellulitis can both have periorbital edema and erythema but the other items mentioned are complications seen with orbital cellulitis and not preseptal cellulitis.

    The most common complications of orbital cellulitis are subperiosteal abscess and orbital abscess. Subperiosteal abscess occurs in 15 to 59 percent of cases in various retrospective series. Marked displacement of globe is suggestive of abscess. CT scan of orbits and sinuses, or surgery are necessary to make the diagnosis. Orbital abscesses have been reported in up to 24% of cases of orbital cellulitis. More severe proptosis, opthalmoplegia and pain with eye movements are seen with orbital abscess.

    Vision loss occurs in 3-11% of patients with orbital cellulitis. Vision loss thought to occur from several processes including optic neuritis (resulting from inflammation from nearby infection), ischemia (resulting from thrombophlebitis along orbital veins), pressure resulting in central retinal artery occlusion.

    Cavernous sinus thrombosis can occur but is a rare complication. Severe headache, intractable vomiting, mental status changes, cranial nerve palsies may be seen. Bilateral cranial nerve palsies can be a sign of bilateral cavernous sinus thrombosis.

    1. A—Vancomycin and ampicillin-sulbactam

    Most commonly identified pathogens in orbital cellulitis are streptococci followed by staph aureus. Less common causes of orbital cellulitis include Haemophilus influenzae and nonspore-forming anaerobes, Aeromonas hydrophila, Pseudomonas aeruginosa and Eikenella corrodens . Some cases are polymicrobial with combination of aerobic and anaerobic bacteria. Less common causes include fungi, especially Mucorales (mucormycosis) and Aspergillus. Consider in immunocompromised patients—mucormycosis in diabetics, aspergillus with severe neutropenia or HIV, including HIV infection.

    Antibiotic treatment includes parenterally administered broad-spectrum regimen targeted at S. aureus (including MRSA), S. pneumoniae and other streptococci, and gram-negative bacilli. When intracranial extension is suspected, the regimen should also include coverage for anaerobes. Regimens include combination of:

    Vancomycin plus one of the following:

    • Ceftriaxone or
    • Cefotaxime or
    • Ampicillin-sulbactam or
    • Piperacillin-tazobactam

    If concerned for intracranial extension, add metronidazole to cover anaerobes if using ceftriaxone or cefotaxime.

    Consult ophthalmology and ENT early—these patient require frequent and repeat physical examination with ophthalmologic and/or otolaryngologic expertise and surgery is sometimes required.

     

    Pearls:

    Distinguishing clinical features of orbital cellulitis include ophthalmoplegia, pain with eye movements, and proptosis.

    When diagnosis between preseptal and orbital cellulitis uncertain, obtain CT scan with contrast to make diagnosis.

     

    Sources:

    Gappy, et al. Orbital Cellulitis. Feb 4 2014. Up to Date.

    Rosen’s Emergency Medicine, 7th Edition.

    http://emedicine.medscape.com/article/1217858-overview

One Response

  1. This kid is toxic (febrile) and needs to be admitted for IV antibiotics. Realistically, for this particular patient, I would probably start something with MRSA coverage (likely Vancomycin and Ampicillin/Sulbactam), particularly given her generally toxic appearance and the relatively high MRSA prevalence in our community. In general though, the textbook (Rosen’s) answer for initial IV treatment is Ceftriaxone alone.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: