Overwhelming orbital cellulitis in a neonate
- 1 Paediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
- 2 Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
- Correspondence to Dr Venkataseshan Sundaram; venkatpgi@gmail.com
Abstract
This article discusses a rare ophthalmic manifestation of neonatal bacterial infection and its management, including surgical drainage. The case discussed is that of a neonate who presented with rapidly progressing ophthalmic symptoms suggestive of orbital cellulitis. The neonate also had extensive intracranial involvement and had spread to contiguous structures causing a temporal lobe abscess. As there was no local injury, a haematogenous spread was strongly considered. With blood culture and pus culture yielding the growth of Staphylococcus aureus, systemic antibiotics and surgical interventions were required to successfully manage the neonate. Through this case report, we emphasise that orbital infections are grave in neonates and may culminate into devastating intracranial complications; hence, it necessitates appropriate medical and surgical interventions right from hospital admission.
Background
Orbital cellulitis is a serious infection of the orbit that involves the tissues posterior to the orbital septum and can result in significant complications which include visual loss, cavernous sinus thrombosis, meningitis, carotid occlusion and intracranial abscess.1 The traditional classification of orbital infections proposed by Chandler et al in 1970 would be difficult to apply in neonates owing to increased local and systemic manifestations in neonates.2 The incidence of orbital cellulitis in the paediatric age group varies between 0% and 25% according to various studies, but neonatal incidences have not been yet explored.3 The causative organisms of orbital cellulitis are commonly bacterial but can also be polymicrobial, often including aerobic and anaerobic bacteria and even fungal or mycobacteria. The most common bacterial organisms causing orbital cellulitis are Staphylococcus aureus and Streptococcus species.4 Orbital cellulitis and abscess formation can occur either due to contiguous spread from infected areas like paranasal sinuses, eyelids, tooth or from endogenous sources during septicaemia by haematogenous route.3 In the literature, the most common predisposing factor for neonatal orbital cellulitis has been reported as ethmoid sinusitis.5
The clinical picture, which includes the classical signs of cellulitis such as eyelid swelling, erythema, chemosis, proptosis and ocular mobility impairment, highly indicates an infection within the orbit. The diagnosis of orbital cellulitis can be confirmed by imaging modalities such as CT and MRI. MRI is superior to CT scan because it helps in monitoring soft tissue disease progression.6 Treatment includes appropriate antibiotic therapy guided by culture data and prompt surgical drainage of the abscesses.
Case presentation
A term neonate presented with left eye proptosis and pus discharge. He also had respiratory distress, poor activity and refusal to feed in the past 1 day. He was born to a primigravida mother by emergency caesarean section done for fetal distress. He had a normal perinatal transition with mild respiratory distress until 4 hours of life and was discharged home on day 4 of life on breastfeeds. On day 14 of life, he developed left eyelid redness which progressed over the next 24 hours to eye discharge and proptosis (figure 1). Subsequently, he became lethargic, refused to suck and developed respiratory distress with chest wall retractions.
Photographs at the presentation—left side proptosed eye with extensive exudation (side profile).
At presentation to the emergency department triage, he required continuous positive airway pressure support with 25% oxygen for respiratory distress. Considering the possibility of sepsis with left orbital cellulitis, the treating team initiated broad-spectrum intravenous antibiotics (vancomycin 15 mg/kg/dose and meropenem 40 mg/kg/dose, both three times a day). Ophthalmological examination revealed a proptosed left eye (~4 mm) with oedema, erythema and pus discharge (figure 2). However, there was no involvement of posterior segments of the left eye, and the right eye was normal. Table 1 shows haematological parameters—haemoglobin 155 g/L, total leucocyte count of 12 350 cells/µL and platelets 282 000/µL. These are within the newborn reference ranges. Cerebrospinal fluid (CSF) analysis revealed 3053 cells/µL, out of which 52% was constituted by neutrophils, and CSF protein elevated to 284 mg/dL. This is suggestive of meningitis. Blood culture and pus culture collected from the ocular surface showed the same organism—S. aureus that was Methicillin-sensitive S. aureus (MSSA). Respiratory support was weaned off over the next 2 days, but ocular features persisted up to 14 days. Due to the unusual site of involvement of sepsis, primary immunodeficiency workup was done which was normal. No other organ systems were involved. MRI was done on day 5 of admission which revealed significant ocular and intracranial involvement as described in table 2.
Photographs at the presentation—left side proptosed eye with extensive exudation (front profile).
Laboratory investigations done in our case
Laboratory investigations done in our case
Radiological investigations done in our case
| MRI of the brain | T2 hyperintense collection in the extraconal and intraconal orbital space of the left eye, predominantly on the medial aspect, extending up to the orbital apex. The collection is seen to displace eyeball anterolaterally in the orbital cavity. There is bilateral ethmoid sinusitis. There is also extension intracranially through the optic foramen leading to T2 hyperintense lesions in the temporal lobe and meningitis. Bilateral ethmoid sinusitis is present (figure 4). |
Treatment
Incision and drainage were done from the left supraorbital region on day 3 from the onset. He required a second drainage for an inferomedial collection of the left eye after 4 days as the ocular signs did not improve and MRI revealed persisting collection. Vancomycin 15 mg/kg/dose and meropenem 40 mg/kg/dose both three times per day were administered for 21 days. Although the blood culture report revealed Methicillin-sensitive organism, the decision was taken not to de-escalate and continue with vancomycin based on previous case reports and the severity of the infection. Meropenem was added to cover meningitis as most infections in neonates in this region are due to gram-negative organisms.
Outcome and follow-up
After 2 weeks of the antibiotic course, the neonate had improved, proptosis regressed and the redness disappeared. He had eyelid retraction postoperatively which spontaneously subsided by 3 weeks (figure 3). Ocular movements in all directions of gaze were present. Activity had improved, and he was being exclusively breastfed. Auditory evaluation—Automated Audiometric Brainstem response was normal. He was discharged after 3 weeks of antibiotics. However, he presented again with convulsions—had intensive care unit admission, stayed for 1 week and was discharged on maintenance antiepileptic drugs. Later, he developed refractory convulsions—clinical features were attributed to neonatal insult and sequelae and succumbed thereafter.
Photographs at 3 weeks post-treatment—eyelid retraction of the left eye due to involvement of underlying rectus muscles.
Discussion
Less information is available about the diagnosis and management of neonatal orbital cellulitis. Paediatric guidelines need to be modified for neonatal cases. Cruz et al in 2001 described two cases of neonatal orbital abscesses which occurred secondary to ethmoidal sinusitis.7 Paediatric data suggested staphylococcal ethmoiditis as the most common cause of orbital cellulitis.8 However, in our case, orbital cellulitis presumably had a haematogenous origin with features of sepsis and pneumonia at presentation.
Panton-Valentine leucocidin, a pore-forming toxin produced by most strains of S. aureus that causes leucocyte cell lysis and induces local inflammation, has been associated with increased virulence and increased disease severity.9 10 Lin et al in 2013 published neonatal orbital cellulitis as a rare and fatal entity and recommended a higher dose of vancomycin (120 mg/kg/day for the usual 40 mg/mg/day) for empirical treatment of S. aureus infection in neonates while simultaneously monitoring vancomycin drug levels and monitoring by renal function tests and urine output.5 Alam et al published a retrospective case series of all orbital and periorbital infections over the past 20 years from a tertiary centre. In that, he could find that MSSA was the most common organism isolated from the orbital abscess, and all neonates in that had undergone surgical interventions. Three neonates were identified in total, and all of them had ethmoid sinusitis similar to our case.11 From our experience with the present case, we propose that community-acquired strains usually are Methicillin sensitive—standard neonatal doses may suffice, and on the other hand, hospital-acquired strains are Methicillin-resistant requiring higher doses of vancomycin empirically. In either case, empirical antibiotics need to be tailored later with the availability of culture data after 48–72 hours.12 Linezolid supposedly having better tissue penetration has been suggested as the first-line antibiotic by Rao et al in one Indian case report.13 Anosike et al did a retrospective cohort study where she could show that antibiotic duration of <3 weeks was associated with treatment failure, and we had given both antibiotics vancomycin and meropenem for 3 weeks duration.14
Ocular signs in neonatal orbital cellulitis are uniform with proptosis, chemosis and eye discharge. Salem et al emphasised eyelid retraction as an important sign in neonatal orbital cellulitis, which was evident after 10 days of treatment in our case after the subsidence of lid oedema, which subsided after 3 weeks of treatment.15
CT scan allows rapid confirmation of diagnosis, measures intraconal and intracranial involvement, and guides treatment decisions.16 Contrast-enhanced MRI has added advantage of being radiation free and found better than CT in exactly decoding topological and aetiological diagnosis in orbital cellulitis cases.6
Timing for surgical interventions in the cases of paediatric orbital cellulitis is debatable. Ophthalmologists have different threshold levels for surgical interventions in managing paediatric orbital cellulitis, and there is no neonatal consensus either. Indications for surgical intervention included larger abscesses with mass effect, poor clinical response to initial medical treatment and concurrent intracranial involvement.17 Five-year Malaysian review study described most children can be managed with medical treatment alone. Although, the mean age of the study population was 6.7 years in their study which drastically differs from our case.18 Another study from Greece stated complete ophthalmoplegia or significant visual impairment (acute optic nerve or retinal compromise), or large well-defined abscesses, and children ≥7 years of age were indicators for surgical drainage of orbital abscess.19 Dhingra et al proposed diplopia as a clinical indicator and abscess as a radiological indicator for surgical drainage.20 Based on limited available data, we recommend the presence of severe clinical signs such as proptosis, pus pointing in eyelids, inability to open palpebral fissures and radiological signs such as subperiosteal or orbital abscess; the intracranial extension should expedite early surgical drainage.
Patient’s perspective
I am devastated as I am unable to fetch my daily wages and need to be here around for the investigations and treatment. I am genuinely not sure about what doctors here are planning to preserve my baby’s vision. As explained by doctors about involvement of brain also, I understand that we will not be leaving this hospital hale and hearty. I bestow my full support and confidence in treating team to try their level best.
Learning points
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Early recognition and evaluation in suspected cases due to diminutive interval between onset of symptoms and intracranial or contiguous spread.
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Case-tailored decisions regarding surgical intervention prove to be more beneficial than strict adherence to radiological criteria.
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Community-acquired Staphylococcus aureus strains causing orbital cellulitis are Methicillin-sensitive. However, hospital-acquired strains are resistant, requiring higher doses of vancomycin.
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Long-term neurological and ophthalmological follow-up is warranted in all cases of neonatal orbital cellulitis.
Ethics statements
Patient consent for publication
Footnotes
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Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: VK. The following authors gave final approval of the manuscript: VS.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.
References
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