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Orbital Cellulitis, Subperiosteal Abscess, Sinusitis, and Septicemia Caused by Arcanobacterium haemolyticum
orbit. The film glides over orbital soft tissues, which facilitates insertion and removal. It is easily trimmed with utility scissors. If the film is incorrectly sized, a second template can be cut at no cost and with no waste of time. Thin aluminum wrinkles and bends, necessitating its removal and reshaping. The use of thicker aluminum sheets would eliminate this problem, but they are not as readily available as radiographic film, and they would require additional sterile instruments (such as metal shears and files) for trimming. Because all sizing is done with the radiographic film, the implant fits on the first insertion, which minimizes the number of times the implant must be moved in and out of the orbit. An additional advantage is that the smooth texture of the radiographie film as well as its rigidity can facilitate the insertion of the implant into the orbit. When superimposed over an implant, the template guides the implant into position, and prevents the rough surface of the implant from catching delicate orbital tissues. Once the implant is in place, the template is removed and discarded. We have used this technique for the past six years on more than 60 patients with orbital fractures and have found it to be a useful technique in the repair of orbital defects. REFERENCES 1. Wesley RE. Current techniques for the repair of complex orbital fractures: miniplate fixation and cranial bone grafts. Ophthalmology 1992;99:1766-72. 2. Glassman RD, Manson PN, Vanderkolk CA. Rigid fixation of internal orbital fractures. Plast Reconstr Surg 1990;86:1105.
Orbital Cellulitis, Subperiosteal Abscess, Sinusitis, and Septicemia Caused by Arcanobacterium haemolyticum Jerry G. Ford, M.D., R. Patrick Yeatts, M.D., and Laurence B. Givner, M.D. PURPOSE/METHODS: A 16-year-old boy had orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia. Arcanobacterium haemolyticum was identified as the causative organism. RESULTS/CONCLUSIONS: This organism is a cause of orbital cellulitis and may require aggresV0L.120,
No. 2
sive therapy in order to achieve a therapeutic response.
O
RBITAL CELLULITIS DUE TO Arcanobacterium haemolyticum has been reported in the literature.1 We encountered a case in a 16-year-old boy. The patient had a one-week history of progressively worsening vomiting, diarrhea, fevers, and left upper eyelid erythema and edema. Medical history was not contributory, and the patient had no risk factors for human immunodeficiency virus infection. He was transferred to our service after becoming worse on intravenous ampicillin and sulbactam therapy. On admission, he appeared to be severely ill with shaking chills. His white blood cell count was 19,500/ mm3 with 64% segmented neutrophils. Abnormal ophthalmic findings were limited to the left eye, orbit, and adjacent areas. The left upper eyelid, the left side of the face, and left side of the forehead were edematous and erythematous. His visual acuity was 20/60 without correction; he had no afferent pupillary defect; ductions were restricted in all directions; the globe was proptotic and displaced inferonasally. Computed tomography demonstrated the following: left orbital cellulitis; subperiosteal abscess in the superotemporal orbit; ethmoid, maxillary, and frontal sinusitis; and soft tissue swelling of the eyelid and orbit (Figs. 1 and 2). Left maxillary sinus lavage and left superior anterior orbitotomy were performed in the operating room. Thick purulent material was drained from both the sinus and orbit. Intravenous ceftizoxime, ampicillin, and clindamycin were started, and over the next few days the patient's fever diminished, but his eyelid edema and proptosis decreased only moderately. Cultures from the orbit and sinus grew A. haemolyticum. A blood culture obtained at the time of admission also grew A. haemolyticum as well as Fusobacterium necrophorum. Computed tomography of the orbit performed on postoperative day 6 showed left pansinusitis and residual orbital inflammation. On the next day, he underwent left endoscopie ethmoidectomy, left maxillary antrostomy, a Caldwell-Luc procedure, Departments of Ophthalmology (J.G.F., R.P.Y.) and Pediatrics (L.B.G.), Bowman Gray School of Medicine of Wake Forest University. Inquiries to Jerry G. Ford, M.D., Department of Ophthalmology, Bowman Gray School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1033; E-mail: [email protected].
BRIEF REPORTS
261
Fig. 1 (Ford, Yeatts, and Givner). Computed tomography (axial view) demonstrates left orbital cellulitis, superotemporal location of subperiosteal abscess (arrowheads), ethmoid sinusitis (arrow), and soft tissue swelling.
Fig. 2 (Ford, Yeatts, and Givner). Computed tomography (coronal view) shows left orbital cellulitis, superotemporal location of subperiosteal abscess (arrowhead), and maxillary and ethmoid sinusitis (arrow).
and a second left anterior orbitotomy. Purulent material was removed from each location; all cultures from this procedure had no growth. Thereafter, his eyelid edema and proptosis quickly resolved. Six months later the patient's visual acuity was 20/20 and results of the ocular examination were normal. Arcanobacterium haemolyticum is a gram-positive to a gram-variable pleomorphic rod, which can be cultured both aerobically and anaerobically. Its microbiologic characteristics have been reported in detail2; its pathogenicity is uncertain. It has been confirmed to be a cause of pharyngitis in adolescents and young adults and is a cause of mild skin infections.2 Occasionally it has been noted to be a cause of invasive disease.3 Givner and associates1 reported A. haemolyticum to be the cause of sinusitis and orbital cellulitis in a patient with primary Epstein-Barr virus infection. That patient was also similar to ours in that (1) he was also a 16-year-old boy; (2) he had a delayed response to therapy (also requiring two surgical procedures); and (3) he had positive blood cultures for A. haemolyticum as well as an anaerobic organism (Bacteroides capillosus). Because of the superotemporal location, hematogenous spread may be a likely cause for the subperiosteal abscess.
Arcanobacterium haemolyticum is a potential pathogen of the orbit and possibly has been unrecognized in the past. In our case, partly because of the low level of suspicion, the identity of the gram-positive rod was difficult to ascertain. Therefore, A. haemolyticum should be considered in cases involving a grampositive rod. In our case and the previous reported case,1 the patients developed septicemia, indicating a pathogenic nature of A. haemolyticum. By reporting this case we hope to increase awareness of this organism; if it is identified, aggressive therapy may be needed to obtain a satisfactory therapeutic response.
262
REFERENCES 1. Givner LB, McGehee D, Taber LH, Stein F, Sumaya CV. Sinusitis, orbital cellulitis and polymicrobial bacteremia in a patient with primary Epstein-Barr virus infection. Pediatr Infect Dis J 1984;3:254-6. 2. Waagner DC. Arcanobacterium haemolyticum: biology of the organism and diseases in man. Pediatr Infect Dis J 1991; 10:933-9. 3. Barker KF, Renton NE, Lee PY, James DH. Arcanobacterium haemolyticum wound infection [letter]. J Infect 1992;24: 214-5.
AMERICAN JOURNAL OF OPHTHALMOLOGY
AUGUST 1995
Orbital Cellulitis, Subperiosteal Abscess, Sinusitis, and Septicemia Caused by Arcanobacterium haemolyticum Jerry G. Ford, M.D., R. Patrick Yeatts, M.D., and Laurence B. Givner, M.D. PURPOSE/METHODS: A 16-year-old boy had orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia. Arcanobacterium haemolyticum was identified as the causative organism. RESULTS/CONCLUSIONS: This organism is a cause of orbital cellulitis and may require aggresV0L.120,
No. 2
sive therapy in order to achieve a therapeutic response.
O
RBITAL CELLULITIS DUE TO Arcanobacterium haemolyticum has been reported in the literature.1 We encountered a case in a 16-year-old boy. The patient had a one-week history of progressively worsening vomiting, diarrhea, fevers, and left upper eyelid erythema and edema. Medical history was not contributory, and the patient had no risk factors for human immunodeficiency virus infection. He was transferred to our service after becoming worse on intravenous ampicillin and sulbactam therapy. On admission, he appeared to be severely ill with shaking chills. His white blood cell count was 19,500/ mm3 with 64% segmented neutrophils. Abnormal ophthalmic findings were limited to the left eye, orbit, and adjacent areas. The left upper eyelid, the left side of the face, and left side of the forehead were edematous and erythematous. His visual acuity was 20/60 without correction; he had no afferent pupillary defect; ductions were restricted in all directions; the globe was proptotic and displaced inferonasally. Computed tomography demonstrated the following: left orbital cellulitis; subperiosteal abscess in the superotemporal orbit; ethmoid, maxillary, and frontal sinusitis; and soft tissue swelling of the eyelid and orbit (Figs. 1 and 2). Left maxillary sinus lavage and left superior anterior orbitotomy were performed in the operating room. Thick purulent material was drained from both the sinus and orbit. Intravenous ceftizoxime, ampicillin, and clindamycin were started, and over the next few days the patient's fever diminished, but his eyelid edema and proptosis decreased only moderately. Cultures from the orbit and sinus grew A. haemolyticum. A blood culture obtained at the time of admission also grew A. haemolyticum as well as Fusobacterium necrophorum. Computed tomography of the orbit performed on postoperative day 6 showed left pansinusitis and residual orbital inflammation. On the next day, he underwent left endoscopie ethmoidectomy, left maxillary antrostomy, a Caldwell-Luc procedure, Departments of Ophthalmology (J.G.F., R.P.Y.) and Pediatrics (L.B.G.), Bowman Gray School of Medicine of Wake Forest University. Inquiries to Jerry G. Ford, M.D., Department of Ophthalmology, Bowman Gray School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1033; E-mail: [email protected].
BRIEF REPORTS
261
Fig. 1 (Ford, Yeatts, and Givner). Computed tomography (axial view) demonstrates left orbital cellulitis, superotemporal location of subperiosteal abscess (arrowheads), ethmoid sinusitis (arrow), and soft tissue swelling.
Fig. 2 (Ford, Yeatts, and Givner). Computed tomography (coronal view) shows left orbital cellulitis, superotemporal location of subperiosteal abscess (arrowhead), and maxillary and ethmoid sinusitis (arrow).
and a second left anterior orbitotomy. Purulent material was removed from each location; all cultures from this procedure had no growth. Thereafter, his eyelid edema and proptosis quickly resolved. Six months later the patient's visual acuity was 20/20 and results of the ocular examination were normal. Arcanobacterium haemolyticum is a gram-positive to a gram-variable pleomorphic rod, which can be cultured both aerobically and anaerobically. Its microbiologic characteristics have been reported in detail2; its pathogenicity is uncertain. It has been confirmed to be a cause of pharyngitis in adolescents and young adults and is a cause of mild skin infections.2 Occasionally it has been noted to be a cause of invasive disease.3 Givner and associates1 reported A. haemolyticum to be the cause of sinusitis and orbital cellulitis in a patient with primary Epstein-Barr virus infection. That patient was also similar to ours in that (1) he was also a 16-year-old boy; (2) he had a delayed response to therapy (also requiring two surgical procedures); and (3) he had positive blood cultures for A. haemolyticum as well as an anaerobic organism (Bacteroides capillosus). Because of the superotemporal location, hematogenous spread may be a likely cause for the subperiosteal abscess.
Arcanobacterium haemolyticum is a potential pathogen of the orbit and possibly has been unrecognized in the past. In our case, partly because of the low level of suspicion, the identity of the gram-positive rod was difficult to ascertain. Therefore, A. haemolyticum should be considered in cases involving a grampositive rod. In our case and the previous reported case,1 the patients developed septicemia, indicating a pathogenic nature of A. haemolyticum. By reporting this case we hope to increase awareness of this organism; if it is identified, aggressive therapy may be needed to obtain a satisfactory therapeutic response.
262
REFERENCES 1. Givner LB, McGehee D, Taber LH, Stein F, Sumaya CV. Sinusitis, orbital cellulitis and polymicrobial bacteremia in a patient with primary Epstein-Barr virus infection. Pediatr Infect Dis J 1984;3:254-6. 2. Waagner DC. Arcanobacterium haemolyticum: biology of the organism and diseases in man. Pediatr Infect Dis J 1991; 10:933-9. 3. Barker KF, Renton NE, Lee PY, James DH. Arcanobacterium haemolyticum wound infection [letter]. J Infect 1992;24: 214-5.
AMERICAN JOURNAL OF OPHTHALMOLOGY
AUGUST 1995