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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 77-80

A Case of bacterial orbital cellulitis with complete ophthalmoplegia


1 Department of General Medicine, MR Medical College, Kalaburgi, Karnataka, India
2 Department of Medicine, MR Medical College, Gulbarga, Karnataka, India

Date of Submission20-Aug-2019
Date of Acceptance05-Jan-2020
Date of Web Publication18-Apr-2020

Correspondence Address:
Dr. Hemanth Ghanta
Room No: 111, PG Boys Hostel, Basaveshwar Teaching and General Hospital, Sedam Road, Kalaburgi - 585 105, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_42_19

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  Abstract 


Orbital cellulitis (OC) refers to acute infection of soft tissues of the orbit behind orbital septum. As many as 11% cases of OC result in visual loss. Here, we report a 60-year-old female who is a known case of Type 2 diabetes mellitus presented with complaints of right-sided headache, unable to open right eyelid, and unable to move eyeball for 1 month. Magnetic resonance imaging brain with orbit contrast done showed right-sided OC with forming abscess. Nasal endoscopy was done and nasal swab culture showed growth of Staphylococcus aureus. The patient was kept on antibiotics and was discharged after improvement. Prompt diagnosis and proper management are essential for curing the patient with OC. This is particularly important to prevent visual loss and other severe life-threatening complications.

Keywords: Diabetes mellitus, orbital cellulitis, Staphylococcus aureus


How to cite this article:
Ghanta H, Harsoor S. A Case of bacterial orbital cellulitis with complete ophthalmoplegia. APIK J Int Med 2020;8:77-80

How to cite this URL:
Ghanta H, Harsoor S. A Case of bacterial orbital cellulitis with complete ophthalmoplegia. APIK J Int Med [serial online] 2020 [cited 2020 Jul 5];8:77-80. Available from: http://www.ajim.in/text.asp?2020/8/2/77/282844




  Introduction Top


Orbital cellulitis (OC) is a septic process behind the orbital septum between the ethmoid and orbitary tissue, representing the most common cause of unilateral exophthalmos which can be sight- and life-threatening.

It can occur in any age group but is more common in children. Streptococcus pneumonia, Staphylococcus aureus, Streptococcus pyogenes, and Haemophilus influenza are common causative organisms.

It is most frequently due to extension of inflammation from neighboring parts, especially the nasal sinuses. Other causes include penetrating injury of the orbit, metastatic infection from breast abscess, puerperal sepsis, thrombophlebitis of legs, and septicemia.

Usually, it presents with swelling and severe pain of eyeball associated with fever, restriction of ocular movements, and loss of vision

OC is an ocular emergency that can lead to life-threatening complications, such as cavernous sinus thrombosis, meningitis, and brain abscess. Careful history-taking and physical examination must be done for fast disease recognition and proper management.


  Case Report Top


A 60-year-old female patient presented with right-sided headache, unable to open right eyelid, and unable to move the right eyeball in all directions associated with pain in the right eye and diminution of vision in the right eye for 1 month. There was neither associated with redness nor swelling of eyelids.

There was no history of any recent trauma or any recent fever or constitutional symptoms. She had been diagnosed with Type 2 diabetes mellitus 4 years back and was on regular oral medications for the same. Her surgical history was unremarkable. She denied any recent travel history or sick contacts. Before this illness, she had reportedly normal vision.

On examination, she was alert and oriented to time, place, and person.

On inspection, her right eye had ptosis and has restricted movement of eyeball in all directions [Figure 1]. Her right eye is neither tense nor tender. Her both pupils are equal and reactive to light. Her left eye is normal. Her right eye had significant visual loss and was only able to discern flashes of light. Her vision in the left eye was 6/6 but in the right eye was limited to finger counting at 3 feet. Fundoscopy of both eyes was normal.
Figure 1: Patient on day 1 of admission with right eye ptosis and restricted movements of eye ball

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The rest of physical examination was unremarkable.

Her initial laboratory tests are provided in [Table 1].
Table 1: Lab parameters of the patient

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Magnetic resonance imaging (MRI) scan of brain and orbits with contrast showed [Figure 2], [Figure 3], [Figure 4], [Figure 5]
Figure 2: Magnetic resonance imaging brain with contrast showing ill-defined lesion along the medial margin of right orbit traversing posteriorly from preseptal to postseptal space in close relation to medial rectus muscle

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Figure 3: Lesion seen along the medial margin of right orbit

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Figure 4: Retro-orbital fat in the vicinity of the lesion showing subtle fat stranding, with subtle enhancement of optic nerve sheath

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Figure 5: The lesion in right orbit extending posteriorly via orbital apex abutting optic nerve along its course and further extends intracranially infiltrating right cavernous sinus measuring 6.1 cm × 0.7 cm

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  1. Right-sided OC with forming abscess measuring 6.1 cm × 0.7 cm with extension into the right cavernous sinus
  2. Bilateral ethmoidal sinusitis.


Computed tomographic (CT) scan of paranasal sinuses showed

  1. Bilateral maxillary and ethmoidal sinusitis and right-sided frontal sinusitis
  2. Soft tissue density lesion along medial wall of right orbit possibly inflammatory.


Nasal endoscopy was done and nasal swab was taken and sent for culture and sensitivity in which S. aureus was isolated

The patient was diagnosed with OC and was treated with intravenous (IV) linezolid. Five days after starting treatment, minimal movement of the right eyelid was noted which initially she was not able to move. In addition, minimal movement of the right eyeball was noted, which she was initially not able to move. The patient was discharged with oral linezolid and was on follow-up.


  Discussion Top


OC is defined as an infection of the orbital contents posterior to the orbital septum, namely the ocular muscles and fat.[1]

A similar yet more benign condition is preseptal cellulitis (PSC), which is the infection of orbital contents anterior to the orbital septum.[1] The orbital septum is a thin membrane continuing from the periosteum of the orbit to the tarsal plate. Infection of the eye globe itself is termed endophthalmitis.[1]

While both PSC and OC may present similarly with eyelid swelling, key signs that indicate OC include proptosis, pain with eye movement, and ophthalmoplegia. If the infection extends far enough to involve the optic nerve, visual impairment may also be present. The ophthalmologist's findings further pointed out to the diagnosis of an advanced case of OC with optic nerve involvement.

The most common source of OC is local spread from pre-existing adjacent rhinosinusitis due to proximity of the sinuses to the orbit. The ethmoid and maxillary sinuses are most frequently implicated, followed by sphenoid and frontal sinuses which develop later in life at around 6 years of age.[2] The thin bony orbital walls can easily be damaged from an adjacent sinus infection causing focal areas of osteitis allowing for spread of pathogens into the orbit. Naturally present focal osseous defects in the orbital walls (i.e. orbital wall fissures and foramina which allow for passage of vessels and nerves) can also contribute to the spread. Another significant factor is the valveless venous drainage of the face. This allows direct two-way communication between the veins of the face, sinuses, nasal cavity, orbit, pterygoid plexus, and cavernous sinus. Therefore, most orbital and intracranial complications of sinusitis are due to retrograde thrombophlebitis.[2]

Other causes of OC include ophthalmic surgery, eye trauma, peribulbar anesthesia, dacryocystitis, and extension from the teeth, middle ear, or face.[1]

Our patient's CT and MRI scans revealed bilateral ethmoidal and maxillary sinusitis and right-sided frontal sinusitis. It is therefore very likely that the source of his OC was from direct extension of the already chronically infected sinuses.

The most common causative agent is S. aureus and streptococci, although atypical bacteria such as Klebsiella, fungal, and polymicrobial infections have been noted in medical literature and are often seen in patients with impaired host defenses.

However, causative agents of OC are generally difficult to identify. They require cultures from the orbit and sinuses which are performed only if surgical intervention is decided. Blood cultures are rarely positive in adults as was the case with our patient.[1] Fungal cultures of the orbits and sinuses should also be performed to rule out invasive fungal infection (i.e. mucormycosis).

Once OC is suspected, it is generally advised to perform contrast-enhanced imaging (CT/MRI) of the orbit to identify potential complications, particularly if the patient presents with advanced symptoms, visual impairment, or signs of central nervous system involvement. Complications include subperiosteal abscess, orbital abscess, optic nerve involvement, leading to vision loss, central retinal artery occlusion, and intracranial extensions (cavernous sinus thrombosis and cerebral abscess).

OC associated with an intracranial extension is an extremely rare presentation, and the incidence is unknown. In addition, it is approximated that 3%–6% of patients hospitalized for sinusitis may develop intracranial complications.[3]

On reviewing the available medical literature, we were able to find only a handful of case reports documenting this rare presentation of OC complicated by brain abscesses. Bilir et al. described a case of OC in a diabetes mellitus patient complicated with cavernous sinus thrombosis.[4] Constantin et al. described the case of a 12-year-old who presented with features of OC and headache but without exophthalmia or fever. The CT scan revealed a right frontal lobe abscess and maxillary, sphenoidal, and ethmoidal sinusitis. The patient was operated on and initially underwent surgical clearance of the ethmoidal and maxillary sinus collections and an adenoidectomy. This was followed by a craniotomy with excision of the brain abscess and antibiotics. The patient made a complete recovery.[5]

Once OC is suspected, the patient requires urgent IV antibiotic therapy. A frequently used regime includes vancomycin (for MRSA coverage) plus ceftriaxone. If intracranial extension is suspected, metronidazole should be started to provide coverage against anaerobes.[6]

In patients failing to improve or those with worsening symptoms, surgical management may be initiated. This involves performing surgical biopsies to identify the causative agent and excision/draining of any infective foci. As the above case reports show, patients with brain abscesses secondary to OC often undergo multiple surgeries—ENT teams operate the sinuses, ophthalmologists operate upon collections in the eye, and neurosurgeons drain cerebral abscesses.

Our patient was treated with IV antibiotics and insulin therapy along with supportive management. Five days after starting treatment, minimal movement of the right eyelid was noted which initially she was not able to move. Further, minimal movement of the right eyeball was noted which she was initially not able to move. The patient was discharged with oral linezolid and was on follow-up.

Diagnosis of OC is based on anamnesis, physical examination, and imaging methods (CT, MRI). It can manifest with presentation of eye pain, discoloration, swelling, fever, limitation of eye movement, proptosis, or decrease in visual acuity; however, primary symptoms are proptosis and ophthalmoplegia. It may cause intracranial complications as meningitis, cavernous sinus thrombosis (CST), or development of abscess.[7]

The cases which do not show improvement in 48–72 h and exhibit ophthalmological signs, such as ophthalmoplegia and paralyzing mydriasis, were those who reach the hospital with intraorbitary or periorbitary abscess. In such cases, surgical drainage of the abscess was performed with endoscopic technique. Endoscopic surgery is less invasive than traditional orbitotomy.[8]

OC is an ocular emergency that can lead to life-threatening complications, such as cavernous sinus thrombosis, meningitis, and brain abscess. Careful history-taking and physical examination must be done for fast disease recognition and proper management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Orbital Cellulitis, Update. Available from: http://www.uptodate.com. [Last accessed on 2019 Apr 28].  Back to cited text no. 1
    
2.
Hoxworth JM, Glastonbury CM. Orbital and intracranial complications of acute sinusitis. Neuroimaging Clin N Am 2010;20:511-26.  Back to cited text no. 2
    
3.
Pathogenesis, Clinical Manifestations, and Diagnosis of Brain Abscess, UpToDate. Available from: http://www.uptodate.com. [Last accessed on 2019 Jul 04].  Back to cited text no. 3
    
4.
Bilir BE, Bilir B, Doǧru M, Polat E, Atİl NS, Yilmaz I. A Rare Complication of Orbital Cellulitis in a Diabetic Case: Cavernous Sinus Thrombosis. J Kartal TR 2016;27:233-7. Available from: https://www.journalagent.com/scie/pdfs/KEAH_27_3_233_237%5BA%5D.pdf. [Last accessed on 2019 Jul 05].  Back to cited text no. 4
    
5.
Constantin F, Niculescu PA, Petre O, Balasa D, Tunas A, Rusu I, et al. Orbital cellulitis and brain abscess – Rare complications of maxillo-spheno-ethmoidal rhinosinusitis. Rom J Ophthalmol 2017;61:133-6.  Back to cited text no. 5
    
6.
Treatment and Prognosis of Bacterial Brain Abscess, UpToDate. Available from: http://www.uptodate.com. [Last accessed on 2019 Apr 28].  Back to cited text no. 6
    
7.
O'Connor MM, King MA. Visual diagnosis: 2-month-old girl with left eye swelling, profuse tearing. Pediatr Rev 2013;34:e27-30.  Back to cited text no. 7
    
8.
Page EL, Wiatrak BJ. Endoscopic vs. external drainage of orbital subperiosteal abscess. Arch Otolaryngol Head Neck Surg 1996;122:737-40.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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