H.P.I.-M.Z 9/9-11a.m.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 2amM.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 AbcessSubperiosteal Abcess

Hospital CourseHospital 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.

MRSAMRSA

Community acquired

– Increased potential for tissue invasion

– Found in young athletes and inmates

– Progresses despite appropriate treatment

Case ReviewCase 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

FindingsFindings

• 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 courseHospital 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 WorkEYE

ENT

ID

NEUROSURGERY

•Team Approach

•History very important in determining the most likely organism. Culture may bedifficult.

•Frequent re-evaluations are necessary.

•Imaging studies are very helpful in diagnosis and monitoring treatment.

•Serious problem can result in death.

HEADS UP

Differential Dx. ProptosisDifferential 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’ granulo-

matosis

ANATOMYANATOMY

Haemophilus InfluenzaeHaemophilus Influenzae