A rare case of trigeminal trophic syndrome with periorbital cellulitis and full-thickness upper eyelid defect in an undiagnosed patient with human immunodeficiency virus: a case report.

BACKGROUND: Trigeminal trophic syndrome is a rare cranial and facial condition caused by damage to the central or peripheral branches of the trigeminal nerve. This syndrome consists of a triad of anesthesia, paresthesia, and crescent-shaped facial ulcer involving the ala nasi and sometimes extending to the upper lip. Although previous screening for human immunodeficiency virus in some patients with trigeminal trophic syndrome was negative, we present a unique case of trigeminal trophic syndrome who tested positive for human immunodeficiency virus with eye complications. CASE PRESENTATION: We present a rare case of trigeminal trophic syndrome in a 44-year-old Black African woman who tested positive for human immunodeficiency virus. She presented with a 6-week history of progressive, persistent, and painless left sided facial and scalp ulcerations that started as small skin erosion. Diagnosis of trigeminal trophic syndrome was made on clinical grounds based on the triad of anesthesia, paresthesia, and unilateral crescent-shaped ulcer in the trigeminal dermatome and her past medical history. The ulcer healed completely after counseling and pharmacological therapy, but she later developed left periorbital cellulitis and left upper eyelid full-thickness defect. CONCLUSION: This is by far the first documented case of trigeminal trophic syndrome with a positive human immunodeficiency virus test. Testing for human immunodeficiency virus in patients with trigeminal trophic syndrome is necessary as this can help improve clinical management and treatment outcomes. Seeking the services of specialists remotely in resource constraint settings is beneficial for managing complications associated with trigeminal trophic syndrome.

VEXAS syndrome as a cause for multifocal, relapsing head and neck inflammation.

VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) is a novel autoinflammatory syndrome. We describe a case of VEXAS syndrome with upper airway and oral cavity involvement which are not well described in the literature.

Herpes Zoster Ophthalmicus Secondary to Periorbital Cellulitis.

Varicella zoster virus (VZV) infection, also commonly known as chickenpox, is a communicable disease most often contracted in childhood via contact, airborne, or droplet transmission. After about a two-week incubation period, patients can experience a prodromal phase, which includes a pruritic vesicular blistering rash with associated constitutional symptoms such as fever, headache, malaise, muscle aches, fatigue, and sore throat. Symptoms are often self-limiting and only require supportive care and observation. We report a case of a 54-year-old female who presented with an unusual background history and was found to have a rare manifestation of herpes zoster virus, presenting as herpes zoster ophthalmicus (HZO).

Orbital complications of pediatric acute rhinosinusitis in the pneumococcal conjugate vaccine era.

OBJECTIVES: To evaluate the impact of the pneumococcal conjugate vaccines (PCVs) introduction on the orbital complications of acute rhino-sinusitis (OC-ARS). METHODS: A retrospective cohort study of all pediatric patients with OC-ARS during the period 2002-2019. Data included clinical, demographic, laboratory, and microbiology findings. Patients were divided into three groups: before PCV7 introduction (group 1), after PCV7 and before PCV13 (group 2), and after PCV13 (group 3). RESULTS: Of 265 enrolled patients, 117, 39, and 109 were assigned to groups 1, 2, and 3. During the study period, a significant decrease was recorded in the percentages of patients in Chandler classification severity category 1, with an increase in patients in category 3 (P = 0.011). The yearly incidence of OC-ARS decreased from 12.64 cases per 100,000 population in 2002 to 5.56 per 100,000 in 2008, and 2.99 per 100,000 in 2019 (P < 0.001). Patients aged 0-4 years showed a dramatic decrease from 29 cases per 100,000 population in 2002 to 4.27 per 100,000 in 2019 (P < 0.001). The pathogens retrieved from all cultures performed were Streptococcus pneumoniae (32.5%), non-typeable Haemophilus influenzae (27.5%), Streptococcus Species, (12.5%), and Staphylococcus aureus (20%), with no changes in distribution during the study periods. Surgery was performed in 28 (10.6%) patients. CONCLUSIONS: A significant decrease was seen in the overall incidence of OC-ARS, mainly attributable to the decrease in patients aged 0-4 years. An increase was recorded in the severity of the disease following PCVs introduction.

Pott's Puffy Tumor: A Case Report on Diagnosis Through Imaging.

Pott's puffy tumor (PPT) is a rare but life-threatening complication of chronic sinusitis, although it can be secondary to other entities such as trauma or insect bites. It is characterized by circumscribed frontal swelling associated with a subperiosteal abscess. Imaging plays a crucial role in diagnosis and early identification of complications, some of which can be life-threatening, including intracerebral and intra-orbital complications. We present a case of a 14-year-old male with non-specific frontal pain and swelling, where the diagnosis of PTT was confirmed through imaging studies. Upon admission, the patient exhibited orbital and intracerebral complications, as shown in MRI and CT scans. Treatment involved a combination of antibiotics and sinus surgery, with close monitoring for orbital and intracranial complications.

A Diagnostic Challenge: Periorbital or Orbital Cellulitis?

The authors present the case of a 39-year-old male who presented to the hospital with worsening eye pain, swelling, and blurred vision of the left eye. His symptoms grew worse despite initial over-the-counter medication and a trip to the urgent care center. A physical exam was concerning for a possible orbital cellulitis given the appearance of the eye and the amount of discomfort, as well as their immunocompromised status, necessitating imaging and workup to confirm the diagnosis. The patient was ultimately diagnosed with periorbital cellulitis and bacterial conjunctivitis, and he received intravenous antibiotics for treatment. This case underscores the importance of a comprehensive diagnostic approach to managing ocular infections.

Neuroblastoma Presenting With Preseptal Cellulitis.

Neuroblastoma, a prevalent extracranial solid tumor commonly afflicting pediatric patients, exhibits a diverse spectrum of clinical presentations. Preseptal cellulitis, a childhood infectious ailment, typically demonstrates a favorable response to conservative antibiotic therapy. In this report, we present the case of a two-year-old female child with refractory preseptal cellulitis, ultimately leading to an unforeseen diagnosis of neuroblastoma. Early radiological assessment upon the onset of preseptal cellulitis serves the dual purpose of excluding severe complications and uncovering latent, rare pathologies when the initial antibiotic regimen proves ineffective.

Abscess volume as a predictor of surgical intervention in children hospitalized with orbital cellulitis: A multicentre cohort study.

IMPORTANCE: Orbital cellulitis with subperiosteal or orbital abscess can result in serious morbidity and mortality in children. Objective volume criterion measurement on cross-sectional imaging is a useful clinical tool to identify patients with abscess who may require surgical drainage. OBJECTIVE: To determine the predictive value of abscess volume and the optimal volume cut-point for surgical intervention. DESIGN: We conducted an observational cohort study using medical records from children hospitalized between 2009 and 2018. SETTING: Multicentre study using data from 6 children's hospitals. PARTICIPANTS: Children were included if they were between 2 months and 18 years of age and hospitalized for an orbital infection with an abscess confirmed on cross-sectional imaging. EXPOSURE: Subperiosteal or orbital abscess volume. MAIN OUTCOME AND MEASURES: The primary outcome was surgical intervention, defined as subperiosteal and/or orbital abscess drainage. Multivariable logistic regression was performed to assess the association of abscess volume with surgery. To determine the optimal abscess volume cut-point, receiver operating characteristic (ROC) analysis was performed using the Youden Index to optimize sensitivity and specificity. RESULTS: Of the 150 participants (mean [SD] age, 8.5 [4.5] years), 68 (45.3%) underwent surgical intervention. On multivariable analysis, larger abscess volume and non-medial abscess location were associated with surgical intervention (abscess volume: adjusted odds ratio [aOR], 1.46; 95% CI, 1.11-1.93; abscess location: aOR, 3.46; 95% CI, 1.4-8.58). ROC analysis demonstrated an optimal abscess volume cut-point of 1.18 mL [AUC: 0.75 (95% CI 0.67-0.83) sensitivity: 66%; specificity: 79%]. CONCLUSIONS AND RELEVANCE: In this multicentre cohort study of 150 children with subperiosteal or orbital abscess, larger abscess volume and non-medial abscess location were significant predictors of surgical intervention. Children with abscesses >1.18 mL should be considered for surgery.

Evaluation of mild periorbital cellulitis and home-based therapy in children-EPOCH study: A prospective single centre cohort study.

BACKGROUND: Paediatric periorbital cellulitis is a common eye condition and warrants prompt management for the prevention of complications. International consensus on the approach to optimal management of children with mild periorbital cellulitis including ambulatory management is lacking. We aimed to prospectively investigate the safety and effectiveness of ambulatory management of children with mild periorbital cellulitis. METHODS: Over a 23-month period, we prospectively enrolled 70 children aged between 2 and 16 years who presented to the emergency department with mild periorbital cellulitis. Demographic and clinical data were collected. Eligible children were commenced on oral antibiotics and were discharged home with close outpatient ambulatory care and ophthalmology follow up. We used descriptive statistics for data presentation. RESULTS: Of the 70 children with mild periorbital cellulitis, 30 (43%) had unknown aetiology. Sixty-five (92%) children received a structured ambulatory follow up. Five children (7%) received inpatient parenteral antibiotics for worsening of local symptoms within 24 h of initial presentation. One child developed orbital cellulitis at follow up. There was no mortality or significant morbidity noted in this group and none of the children needed surgical intervention. CONCLUSIONS: Ambulatory care for children with mild periorbital cellulitis is an effective and safe management strategy. This might prevent hospitalisation, reduce the burden on hospital bed occupancy and promote patient care in the community.

Preseptal Cellulitis Due To Impetigo - A Case Report Of Uncommon Presentation In Pakistan.

We present the case of a 30-year-old woman who presented with 8-month history of intermittent fever, joint pains with morning stiffness, recurrent oral ulcers, photosensitivity, weight loss and hair fall. For the last 2 months, she had developed a dry cough with progressive shortening of breath. On examination, a cachexic lady with malar hyperpigmentation, alopecia, pallor, nail dystrophy and erythema over her hands and feet were noted. There were multiple punched-out skin ulcers of variable size over legs, arms and abdomen usually round in shape with well-defined even wound margins and scant serous discharge. Musculoskeletal examination revealed synovitis of both elbows and a few metacarpophalangeal and proximal interphalangeal joints. Chest X-ray and HRCT showed bilateral ground-glass opacification. Anti-Nuclear Antibody (ANA) was positive, 1:320, homogenous nuclear pattern. Anti-Ro antibody was highly positive and serum complement (C3, C4) levels were reduced. She was diagnosed with Lupus Vasculitis and started on steroids, mycophenolate mofetil and hydroxychloroquine.

Antibiotic Choices for Pediatric Periorbital Cellulitis-A 20-Year Retrospective Study from Taiwan.

The delayed treatment of pediatric periorbital cellulitis may have severe consequences. In addition, the antibiotic efficacy against causative bacteria may change over time, and it is important to understand the appropriate antibiotic options for effective treatment in pediatric patients. We compared the changes in cultured bacteria and drug susceptibility tests between two decades, 2010-2019 and 2000-2009, to establish antibiotics for empirical use. The patient characteristics, etiologies, culture sites, and isolated bacteria, and the antibiotic susceptibility tests of the admitted pediatric patients (n = 207) diagnosed with preseptal and orbital cellulitis during 2000 to 2019, were recorded. Insect/animal bites (p = 0.084) showed an increasing trend, and sinusitis (p = 0.016) showed a significant decrease in the past decades. The most common bacteria were Staphylococcus aureus, and methicillin-resistant S. aureus (MRSA) infections increased in recent decades (p = 0.01). Moreover, we found that vancomycin was ideal for MRSA infections. The decreasing efficacy of oxacillin correlates with the increasing proportion of MRSA in pediatric periorbital cellulitis. Our study thus offers antibiotic choices against the most common isolates that can be administered before culture results are available.

Clinical Markers of Need for Surgery in Orbital Complication of Acute Rhinosinusitis in Children: Overview and Systematic Review.

BACKGROUND: Although they can occur at all ages, orbital (OC) and periorbital cellulitis (POC) prevail in the pediatric population. Acute rhinosinusitis (ARS) is the most frequent predisposing factor of OC. Recent literature has suggested a medical management approach for OC and POC, with surgery reserved only for more severe cases. However, there is still a lack of consensus on the clinical markers of a need for surgery. The aim of this systematic review was to identify clinical markers of a need for surgery in children with OC. Our systematic review, in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) process, yielded 1289 articles finally screened. This resulted in 31 full texts that were included in a qualitative analysis. The results of this review suggest that in children aged over 9 years, large subperiosteal orbital abscesses (SPOAs), impaired vision, ophthalmoplegia, proptosis, elevated C-reactive protein (CRP) and absolute neutrophil counts (ANC), hemodynamic compromise, no clinical improvement after 48/72 h of antibiotic therapy, and a Chandler III score or higher are clinical markers of the need for surgery. However, most of the studies are observational and retrospective, and further studies are needed to identify reliable and repeatable clinical markers of the need for surgery.

Pediatric COVID-19 associated acute rhinosinusitis and periorbital abscess: A case report.

Complications of acute rhinosinusitis(ARS) in the pediatric population can include intra- and extracranial involvement from spread of infection. Though these infections are most commonly preceded by a URI, infection with Sars-CoV-2 (COVID-19) as the inciting event for complicated ARS has rarely been described in the pediatric population. Furthermore, decision making surrounding surgical management of acutely infected patients with COVID-19 remains complicated. This case demonstrates complicated ARS in an otherwise healthy 10-year-old patient with an orbital abscess following COVID-19 infection, ultimately requiring both internal and external surgical approaches for adequate management.

Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections.

OBJECTIVES: To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections. STUDY DESIGN: We conducted a multicenter cohort study of children 2 months to 18 years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors. RESULTS: Of 1579 patients entered, median age was 5.4 years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated with older age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18 years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120 mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/µL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%). CONCLUSIONS: In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.

Tubercular Osteomyelitis of the Orbit Presenting as Periorbital Cellulitis.

PURPOSE: Osteomyelitis of the orbital bones presenting as an orbital cellulitis is a rare form of extrapulmonary tuberculosis (TB). We report a rare case of tubercular osteomyelitis of the orbital bones presenting as a periorbital cellulitis. CASE REPORT: A seven-year-old female child presented to our tertiary eye care center with swelling involving the right eyelids and the right cheek for two months. She had been provisionally diagnosed elsewhere as pre-septal cellulitis and had been given oral antibiotics. We clinically diagnosed her as orbital cellulitis, but her non-responsiveness to intravenous antibiotics prompted us to get a contrast enhanced computed tomography (CECT) of the orbit and paranasal sinuses, which was suggestive of tubercular etiology. However, the patient had no foci for TB elsewhere. We used a relatively new, but rapid test, called Cartridge-based Nucleic Acid Amplification Test (CBNAAT) on the pus aspirate which was positive for TB. Thereafter, the patient was started on anti-tubercular treatment to which she responded wonderfully. CONCLUSION: A high index of suspicion should be kept for TB infection in cases of orbital cellulitis with unusual clinical behavior in an endemic region such as India.

Management of periorbital cellulitis at the Pediatric Emergency Department: A ten years study.

Periorbital cellulitis is a diagnostic and therapeutic emergency, jeopardizing the prognosis for vision and survival. PURPOSE: The goal of this study was to analyze the epidemiological and therapeutic features and outcomes of periorbital cellulitis cases treated in the pediatric emergency department. PATIENTS AND METHODS: A retrospective study including all the children aged between 1 month and 15 years treated for periorbital cellulitis in the Pediatric Emergency Department of the Mohamed VI University Teaching Hospital in Marrakech over a period of 10 years (January 1, 2010-December 31, 2019). RESULTS: In all, 168 cases of periorbital cellulitis were recorded, with an increasing of the number of cases, from 2 in 2010 to 39 in 2019. The most affected age bracket was the group under 5 years of age (62.5%). The most frequent mode of entry was sinusitis (22%). Preseptal cellulitis was most common (76.7%). The main clinical signs found in orbital cellulitis were proptosis (64%) and chemosis (35.8%), versus conjunctival hyperemia (78%) in preseptal cellulitis. Ophthalmoplegia was present in two cases of orbital cellulitis. The right side was most affected (44%). An orbital CT scan was performed in all cases in our study, showing preseptal cellulitis in 129 patients (76.7%), orbital cellulitis in 14 cases (8.3%), subperiosteal abscess in 20 cases (12%) and orbital abscess in 5 cases (3%). Prior treatment with non-steroidal anti-inflammatory medication was noted in 6%. The most commonly used antibiotic was amoxicillin-clavulanic acid. Steroid treatment was prescribed in 6% of cases. Surgical treatment was indicated in 12 patients (7.1%). The mean hospital length of stay was 3 days for the preseptal cases and 8 days for the orbital cases. All patients had good outcomes with medical and/or surgical treatment. With follow-up of over one year, no complications were noted. CONCLUSION: The majority of our cases had positive outcomes, highlighting the advantage of early diagnosis, adapted antibiotic treatment and multidisciplinary care, rendering surgery rarely necessary.

Treatment of a Rare Case of Orbital Necrotizing Fasciitis Utilizing Negative Pressure Wound Therapy.

We present a severe case of orbital necrotizing fasciitis that was treated utilizing negative pressure wound therapy (NPWT).  The conditions caused by the disease and the utility of the treatment were discussed. Additionally, the functionality and the process of the treatment were thoroughly analyzed. Potential complications from utilizing NPWT were also identified. When the patient was tested, it was found that he had intra op cultures with group B Streptococcus pyogenes (Strep pyogenes). CT scans were also conducted to analyze his right lateral periorbital tissue. Subsequently, the patient was admitted to the ICU, where a wound vacuum-assisted closure (VAC) was placed on his right eye. Once the NPWT was complete, the patient was prescribed antibiotics and was able to improve the health within his right eye.

Nasal-type T-cell lymphoma referred as fungal rhinosinusitis: Case report.

NKTCL is a rare and destructive midline tumor that can be easily misdiagnosed as other more common inflammatory processes. The differential diagnosis of NKTCL should always be kept in mind for any lesion of the paranasal sinuses with atypical presentation and nonresponsive to conventional treatments.

The role of adjuvant systemic steroids in the management of periorbital cellulitis secondary to sinusitis: a systematic review and meta-analysis.

PURPOSE: The role of adjuvant systemic corticosteroids in the management of periorbital cellulitis and subperiosteal/orbital abscesses secondary to sinonasal infections is not well understood. Our objective was to systematically review the current evidence on the efficacy and side effects of systemic steroids when used in the management of periorbital cellulitis. METHODOLOGY: A systematic review of literature was conducted in accordance with PRISMA guidance. A systematic search of MEDLINE, Embase and Cochrane databases, MetaRegister and ISI conference proceedings was conducted. The outcomes of interest were duration of inpatient stay, requirement for surgical intervention, adverse effects and recurrent/residual symptoms. RESULTS: Four studies were identified involving 118 patients. Of these, 78 underwent treatment with systemic corticosteroids and 40 were controls. Meta-analysis demonstrated that the mean duration of inpatient stay was significantly shorter in the steroid group (WMD - 2.90 days; 95% CI - 3.07, - 2.73; p < 0.00001). There were no significant differences in requirement for surgical intervention (RR 0.93; 95% CI 0.50, 1.75; p = 0.83). Side effects were reported in 6/78 patients (7.7%), with 5 patients showing signs of hyperactivity and 1 patient with insomnia. These were mild except in one case, which required early cessation of corticosteroids. There was one case of recurrence of symptoms in each cohort (steroid vs. non-steroid) following discharge. CONCLUSIONS: The evidence suggests that systemic corticosteroids may offer some benefit in the management of periorbital cellulitis secondary to sinonasal infections. However, there is significant heterogeneity and risk of bias. A well-designed randomised controlled trial may provide a better insight into the efficacy of systemic steroids for this condition.

Paediatric periorbital cellulitis: A 10-year retrospective case series review.

AIM: To identify the predictors of poor outcome and need for surgical management in paediatric patients with periorbital cellulitis. To assess the adherence to local guidelines in the management of periorbital cellulitis. METHODS: Retrospective descriptive analysis of clinical, laboratory and radiological characteristics of 175 paediatric periorbital cellulitis presentations at a UK teaching hospital over a 10-year period. Regression investigated correlations for continuous and categorical variables. RESULTS: A total of 175 paediatric presentations were diagnosed as periorbital infections over the 10-year period. Of these, 139 had pre-septal cellulitis, 27 had a subperiosteal abscess, 6 had an orbital cellulitis, 1 had an orbital abscess, 1 a cavernous sinus thrombosis and 1 an extradural abscess. Median age at presentation was 5 years (range: 1 month-17 years). In total, 169 (97%) cases received systemic antimicrobial treatment. Cross-sectional imaging occurred in 30% of cases and 18% required surgical intervention. Increasing C-reactive protein was associated with greater risk of post-septal disease and requiring surgery. The best predictors of post-septal disease in the multivariate analysis (R2 = 0.49, P = ≤0.001) were ophthalmoplegia (P = 0.009), proptosis (P = 0.016) and pain on eye movement (P = 0.046). Proptosis was the single most significant predictor of surgical management (R2 = 0.53, P = <0.001). CONCLUSION: Multidisciplinary involvement and early medical management can improve outcomes for most patients. Those who deteriorate despite medical management should be considered for prompt imaging and surgical management to avoid serious life-threatening or sight-threatening complications.