Download CELLULITIS

H.P.I.-M.Z 9/9-11a.m.

40y/o male with swelling,redness,and
drainage from the left eye for last few days.
 E.O.M.’s intact.”No suspicion of deep
infection at this time”.
 Treatment Keflex 500mg Q 6hr P.O. and
check with Ophthalmology in the a.m.
 (1gram of Rocephin i.m.)
M.Z. 9/10 2am

2a.m. 9/10 M..Z. referred from Sauk City E.R.
with severe headache,periorbital pain,
proptosis,lateral globe displacement,and restricted
adduction. (-) A.P.D. V.A. 20/80
 Cat scan:Ethmoid/Maxillary sinusitis and 25
m.m.x11m.m. subperiosteal abscess
 P.M.H. 1996 Mandibular fracture & Ethmoid
(medial wall) fracture(Supramid implant). Dental
work 4 days ago
Subperiosteal Abcess
Hospital Course


Dx.Orbital Cellulitis with Subperiostal abscess.
Team approach P.C.P.,Infectious Disease, and
Oculoplastic surgeon
 Tx. Ceftriaxone 2gm q 12hr.iv, Clindamycin 900
mg q 8 hr,Vancomycin 1 gm,q12 hr. started
immediately
 9/11 (L) orbitotomy with removal of implant and
abscess drainage. Culture alpha Strep &coag.neg
Staph.
 Discharged 9/15 on oral antibiotics, symptoms
resolved vision normal.
MRSA

Community acquired
– Increased potential for tissue invasion
– Found in young athletes and inmates
– Progresses despite appropriate treatment
Case Review
Day 1: 44 yr old male squeezed a pustule in his nose
Day 3: fever and chills developed, treated with
TMP/SMX DS and Rifampin
Day 4: Admitted for eyelid swelling, WBC
24,000.Rx- Vancomycin + Ceftriaxone +
Metronidazole
Day 5: Massive proptosis, ophthalmoplegia,
bilateral vision loss
Findings
• Pupils unreactive, central retinal arteries and
veins occluded
• Congestion of optic discs
• Orbital and brain MRI –bilateral orbital
cellulitis, pansinusitis, cavernous sinus enlargement
•MR venogram confirmed cavernous sinus
thrombosis
Hospital course

Paranasal sinuses drained endoscopically

Day 13: iv heparin and methylprednisolone

In retrospect, may have benefited from
orbital decompression sooner
Preseptal cellulitis RX
Dicloxacillin
Augmentin
Macrolides
Quinolones
3rd gen. Cephalosporin
Orbital Cellulitis
 Ceftriaxone & Metronidazole Vancomycin
 Ampicillin/Sulbactam
 Ticarcillin/Clavulanic acid & Vancomycin
 Imipenen/Meropenem & Vancomycin
 Fluoroquinolone & Clindamycin
 Aztreonam
 Amphotericin
Team Work
EYE
ENT
ID
NEUROSURGERY
HEADS UP
•Team Approach
•History very important in
determining the most likely
organism. Culture may be
difficult.
•Frequent re-evaluations are
necessary.
•Imaging studies are very helpful in
diagnosis and monitoring treatment.
•Serious problem can result in death.
Differential Dx. Proptosis
Infection
Orbital cellulitis
Cavernous sinus thrombosis
Neoplastic
Metastatic Ca
Lymphoma
Rhabdomyosarcoma
Retinoblastoma
Leukemia
Letterer-Siwe disease

Endocrine
Orbital Inflammation
 Pseudotumor
 Orbital myositis

Wegener’ granulomatosis
ANATOMY
Haemophilus Influenzae