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Orbital cellulitis in a burned child
Burns 31 (2005) 650–652 www.elsevier.com/locate/burns
Case report
Orbital cellulitis in a burned child Amjad Ahmad a, Brent Hayek a,*, Stathis Poulakidas b, Richard Gamelli b a
Department of Ophthalmology, Surgical Critical Care and Burns, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA b Department of Surgery, Division of Trauma, Surgical Critical Care and Burns, Loyola University Medical Center, Maywood, IL 60153, USA Accepted 22 December 2004
1. Introduction Orbital cellulitis in the pediatric population is usually secondary to ethmoid sinusitis. The thin medial wall of the orbit and its respective foramina allow infection to spread from the contiguous ethmoid sinuses. We describe a case of septicemia with periorbital and orbital abscess formation in a pediatric burn.
2. Case report A 6-month-old was admitted to our burn center for a 15% TBSA scald burn to his lower extremities, groin, buttocks and abdomen. His past medical history was significant for hydrocephalus. The patient became febrile on hospital day 6. Blood cultures showed infection with methicillin resistant Staphylococcus aureus (MRSA). The patient completed a course of intravenous vancomycin and tobramycin. On hospital day 42 the patient became febrile and developed swelling of the right lower leg. Lower extremity Doppler ultrasound revealed a thrombosis of his common iliac vein. Blood cultures revealed MRSA. Three days later he was noted to have right upper eyelid edema (Plate 1). At this time the ophthalmology service was consulted. On examination, the child was intubated and mildly sedated. Visual acuity was difficult to assess secondary to his level of sedation. The pupils were brisk with no evidence of an afferent papillary defect. The child was moving his eyes and grossly there appeared to be no ocular motility deficit. The right upper lid was swollen with loss of the normal lid crease. The eyelid was mildly erythematous with no palpable fluctuance. Manual palpation of the right orbit revealed increased resistance as compared to the left orbit. The portable slit lamp exam * Corresponding author. Tel.: +1 708 466 0173. E-mail address: [email protected] (B. Hayek). 0305-4179/$30.00 # 2005 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2004.12.011
revealed mild chemosis of the lateral conjunctiva of the right eye. Examination of the left eye was within normal limits. Intraocular pressure and dilated fundus examination were normal bilaterally. Orbital imaging revealed an abscess associated with air in both the lateral orbit and adjacent temporalis fossa (CT image, Plate 2). Using a lid crease incision both abscesses were drained and irrigated with antibiotics (Plate 3). Penrose drains were left in both the orbit and the temporalis fossa. Cultures taken from the orbit revealed growth with MRSA. After 48 h the patient was still febrile and the right temporalis fossa was still draining purulent material. Re-exploration of the wound revealed another collection of purulence in the infratemporal fossa. After irrigating with antibiotics and placement of a drain, the wound was left to granulate. The patient defervesced within 48 h of the second procedure.
3. Discussion Infections are a major complication of burn injury and occur with greatest frequency in the pediatric population [4]. Rodgers et al. prospective study revealed burn wound infections and catheter-associated septicemia as the most common infections. Patients at high risk include those with >30% TBSA, flame and inhalation injury and full thickness burns [4]. The most common causative organism was S. aureus, most likely from pre-existent colonization. We believe that thrombophlebitis may also place patients at greater risk of further infectious complications. Thrombophlebitis in conjunction with septicemia has been associated with metastatic infectious emboli [1,2,6]. Our patient had an infected intravenous line, bacteremia and thrombophlebitis. Immune dysfunction related to burn injury has been demonstrated in clinical practice and experimentally [3]. Our patient had very few clinical signs that would point to an
A. Ahmad et al. / Burns 31 (2005) 650–652
651
Plate 1. Note slight fullness of right temporalis fossa, trace erythema and loss of eyelid crease.
underlying orbital infection. Immunocompetent children with orbital cellulitis have significant orbital and eyelid edema, proptosis and extraocular muscle dysfunction. Burn patients with eyelid erythema and fever should be aggressively evaluated and treated for possible underlying
infection. Untreated orbital cellulitis can lead to permanent loss of vision and even death. Management of orbital abscesses requires a team approach consisting of ophthalmologists, otolaryngologists, infectious disease specialists and the primary care team, who
Plate 2. Demonstrates air densities in the right temporalis fossa and adjacent orbit suggestive of abscess formation.
652
A. Ahmad et al. / Burns 31 (2005) 650–652
Plate 3. Drainage of underlying abscesses using a lateral upper eyelid crease approach.
in this case was the burn surgical team. In some cases, orbital abscesses associated with sinusitis can be treated conservatively with intravenous antibiotics and nasal decongestants. Surgical management requires drainage of not only the orbit but of the offending sinuses. An endoscopic approach can access the medial and inferior orbit and paranasal sinuses. Laterally based abscesses require a periorbital approach, usually through an eyelid incision. Orbital imaging revealed our patient to have infection in the lateral orbit and adjacent temporalis fossa. Immediate drainage of the infection was performed through a lid crease incision. After incising the periosteum of the lateral orbital rim a subperiosteal plane was entered along the inside of the orbit. Copious purulent material was removed and the orbit irrigated with tobramycin. Using this incision the temporalis fossa was also drained of all purulent material. Children must be observed closely even after drainage of orbital infection. In most cases, adequate drainage of orbital abscesses will immediately relieve pain and any visual loss. Eyelid edema often lags behind other clinical parameters like fever and activity level. Continued fever or unchanged clinical picture must make the clinician question if there is further infection that has either re-collected or if there is another abscess that was not drained. Our patient had continued fever after his initial drainage procedure. Further exploration of the wound revealed collection of purulence in the infratemporal fossa. The patient defervesced soon after the second procedure. In conclusion, pediatric burn patients with eyelid erythema and septicemia must be evaluated for underlying
orbital infections. Clinical features, which are usually significant like proptosis, eyelid inflammation and extraocular muscle dysfunction may be minimal in pediatric burn patients secondary to the immunocompromised state of these patients. Treatment must be aggressive to prevent loss of vision and further infectious complications like meningitis or brain abscess.
Acknowledgments We wish to acknowledge the nursing staff at Loyola’s burn unit for their hard work and commitment to care for these challenging patients.
References [1] Reper P, Van Der Rest P, Creemers A, Vandenen D, Vanderkelen A. Medical treatment of a central vein suppurative thrombosis with cerebral metastatic abscesses in a burned child. Burns 2001;27(6):662–3. [2] Riedel G, Becker S, Steen M. Hematogenous cervical spondylodiscitis after severe burn injury. Burns 2001;27(8):843–8. [3] Rodgers G, Kim J, Long S. Fever in burned children and its association with infectious complications. Clin Pediatr 2000;39:553–6. [4] Rodgers G, Mortensen J, Fisher M, Lo A, Cresswell A, Long S. Predictors of infectious complications after burn injuries in children. Pediatr Infect Dis J 2000;19:990–5. [6] Khan EA, Correa AG, Baker CJ. Suppurative thrombophlebitis in children: a 10-year experience. Pediatr Infect Dis J 1997;16:63–7.
Case report
Orbital cellulitis in a burned child Amjad Ahmad a, Brent Hayek a,*, Stathis Poulakidas b, Richard Gamelli b a
Department of Ophthalmology, Surgical Critical Care and Burns, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA b Department of Surgery, Division of Trauma, Surgical Critical Care and Burns, Loyola University Medical Center, Maywood, IL 60153, USA Accepted 22 December 2004
1. Introduction Orbital cellulitis in the pediatric population is usually secondary to ethmoid sinusitis. The thin medial wall of the orbit and its respective foramina allow infection to spread from the contiguous ethmoid sinuses. We describe a case of septicemia with periorbital and orbital abscess formation in a pediatric burn.
2. Case report A 6-month-old was admitted to our burn center for a 15% TBSA scald burn to his lower extremities, groin, buttocks and abdomen. His past medical history was significant for hydrocephalus. The patient became febrile on hospital day 6. Blood cultures showed infection with methicillin resistant Staphylococcus aureus (MRSA). The patient completed a course of intravenous vancomycin and tobramycin. On hospital day 42 the patient became febrile and developed swelling of the right lower leg. Lower extremity Doppler ultrasound revealed a thrombosis of his common iliac vein. Blood cultures revealed MRSA. Three days later he was noted to have right upper eyelid edema (Plate 1). At this time the ophthalmology service was consulted. On examination, the child was intubated and mildly sedated. Visual acuity was difficult to assess secondary to his level of sedation. The pupils were brisk with no evidence of an afferent papillary defect. The child was moving his eyes and grossly there appeared to be no ocular motility deficit. The right upper lid was swollen with loss of the normal lid crease. The eyelid was mildly erythematous with no palpable fluctuance. Manual palpation of the right orbit revealed increased resistance as compared to the left orbit. The portable slit lamp exam * Corresponding author. Tel.: +1 708 466 0173. E-mail address: [email protected] (B. Hayek). 0305-4179/$30.00 # 2005 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2004.12.011
revealed mild chemosis of the lateral conjunctiva of the right eye. Examination of the left eye was within normal limits. Intraocular pressure and dilated fundus examination were normal bilaterally. Orbital imaging revealed an abscess associated with air in both the lateral orbit and adjacent temporalis fossa (CT image, Plate 2). Using a lid crease incision both abscesses were drained and irrigated with antibiotics (Plate 3). Penrose drains were left in both the orbit and the temporalis fossa. Cultures taken from the orbit revealed growth with MRSA. After 48 h the patient was still febrile and the right temporalis fossa was still draining purulent material. Re-exploration of the wound revealed another collection of purulence in the infratemporal fossa. After irrigating with antibiotics and placement of a drain, the wound was left to granulate. The patient defervesced within 48 h of the second procedure.
3. Discussion Infections are a major complication of burn injury and occur with greatest frequency in the pediatric population [4]. Rodgers et al. prospective study revealed burn wound infections and catheter-associated septicemia as the most common infections. Patients at high risk include those with >30% TBSA, flame and inhalation injury and full thickness burns [4]. The most common causative organism was S. aureus, most likely from pre-existent colonization. We believe that thrombophlebitis may also place patients at greater risk of further infectious complications. Thrombophlebitis in conjunction with septicemia has been associated with metastatic infectious emboli [1,2,6]. Our patient had an infected intravenous line, bacteremia and thrombophlebitis. Immune dysfunction related to burn injury has been demonstrated in clinical practice and experimentally [3]. Our patient had very few clinical signs that would point to an
A. Ahmad et al. / Burns 31 (2005) 650–652
651
Plate 1. Note slight fullness of right temporalis fossa, trace erythema and loss of eyelid crease.
underlying orbital infection. Immunocompetent children with orbital cellulitis have significant orbital and eyelid edema, proptosis and extraocular muscle dysfunction. Burn patients with eyelid erythema and fever should be aggressively evaluated and treated for possible underlying
infection. Untreated orbital cellulitis can lead to permanent loss of vision and even death. Management of orbital abscesses requires a team approach consisting of ophthalmologists, otolaryngologists, infectious disease specialists and the primary care team, who
Plate 2. Demonstrates air densities in the right temporalis fossa and adjacent orbit suggestive of abscess formation.
652
A. Ahmad et al. / Burns 31 (2005) 650–652
Plate 3. Drainage of underlying abscesses using a lateral upper eyelid crease approach.
in this case was the burn surgical team. In some cases, orbital abscesses associated with sinusitis can be treated conservatively with intravenous antibiotics and nasal decongestants. Surgical management requires drainage of not only the orbit but of the offending sinuses. An endoscopic approach can access the medial and inferior orbit and paranasal sinuses. Laterally based abscesses require a periorbital approach, usually through an eyelid incision. Orbital imaging revealed our patient to have infection in the lateral orbit and adjacent temporalis fossa. Immediate drainage of the infection was performed through a lid crease incision. After incising the periosteum of the lateral orbital rim a subperiosteal plane was entered along the inside of the orbit. Copious purulent material was removed and the orbit irrigated with tobramycin. Using this incision the temporalis fossa was also drained of all purulent material. Children must be observed closely even after drainage of orbital infection. In most cases, adequate drainage of orbital abscesses will immediately relieve pain and any visual loss. Eyelid edema often lags behind other clinical parameters like fever and activity level. Continued fever or unchanged clinical picture must make the clinician question if there is further infection that has either re-collected or if there is another abscess that was not drained. Our patient had continued fever after his initial drainage procedure. Further exploration of the wound revealed collection of purulence in the infratemporal fossa. The patient defervesced soon after the second procedure. In conclusion, pediatric burn patients with eyelid erythema and septicemia must be evaluated for underlying
orbital infections. Clinical features, which are usually significant like proptosis, eyelid inflammation and extraocular muscle dysfunction may be minimal in pediatric burn patients secondary to the immunocompromised state of these patients. Treatment must be aggressive to prevent loss of vision and further infectious complications like meningitis or brain abscess.
Acknowledgments We wish to acknowledge the nursing staff at Loyola’s burn unit for their hard work and commitment to care for these challenging patients.
References [1] Reper P, Van Der Rest P, Creemers A, Vandenen D, Vanderkelen A. Medical treatment of a central vein suppurative thrombosis with cerebral metastatic abscesses in a burned child. Burns 2001;27(6):662–3. [2] Riedel G, Becker S, Steen M. Hematogenous cervical spondylodiscitis after severe burn injury. Burns 2001;27(8):843–8. [3] Rodgers G, Kim J, Long S. Fever in burned children and its association with infectious complications. Clin Pediatr 2000;39:553–6. [4] Rodgers G, Mortensen J, Fisher M, Lo A, Cresswell A, Long S. Predictors of infectious complications after burn injuries in children. Pediatr Infect Dis J 2000;19:990–5. [6] Khan EA, Correa AG, Baker CJ. Suppurative thrombophlebitis in children: a 10-year experience. Pediatr Infect Dis J 1997;16:63–7.