Rhino-Orbital Cerebral Mucormycosis in a Healthy Female Child: Case Report.

Mucormycosis is a potentially fatal condition with a high mortality rate, particularly when there is extra nasal involvement, and it is rare for patients with fungal brain disease to survive. It mostly affects patients who are metabolically or immunologically compromised, which constitutes one of the three classical stages of the progression of Rhino-Orbito-Cerebral Mucormycosis (ROCM). Stage I: infection of the nasal mucosa and paranasal sinuses; Stage II: orbital involvement; Stage III: cerebral involvement.Here, we report a case of rhino-orbital cerebral mucormycosis in a 14-year-old girl with no known risk factor who presented with periorbital edema, right eye proptosis, fever, and extreme facial pain, which progressively worsened to confusion and left leg weakness in 3 days after admission. The final diagnosis was rhino-orbital-cerebral mucormycosis. The infection was successfully treated using liposomal amphotericin and surgical debridement to remove infected orbital tissue. Mucormycosis is a potentially fatal disease that necessitates prompt diagnosis and treatment. Children are rarely infected with mucormycosis. The majority of studies show that people are typically between 40 and 50 years old. ROCM is typically diagnosed using clinical symptoms and histopathologic evaluation; however, imaging is critical in determining the presence of intracranial lesions. The standard treatment for ROCM is amphotericin B at a recommended dose of 1.0-1.5 mg/kg/day for weeks or months, depending on the clinical response and severity of adverse drug reactions, particularly nephrotoxicity.Rhino-orbital cerebral mucormycosis in a healthy female child is uncommon; early diagnosis and prompt treatment with Amphotericin B should be necessary. Devastating consequences will result from a delayed diagnosis.

Qualitative and Quantitative Magnetic Resonance Imaging in Bacterial Orbital Cellulitis.

PURPOSE: To summarise the qualitative and quantitative parameters of bacterial orbital cellulitis (OC) on magnetic resonance imaging (MRI) and explore their clinical correlations. METHODS: Multi-centre retrospective study with inclusion of patients of all ages with OC who underwent MRI. Patients with isolated pre-septal cellulitis, bilateral disease and poor-quality scans were excluded. An enlargement ratio for extraocular muscles (EOMs) was calculated by dividing maximal EOM measurements from the affected side by the contralateral side. RESULTS: Twenty MRI scans from twenty patients (Mean age: 40.8 ± 24.3 years old, M: F = 15:5) between 2011 and 2022 were analysed. Three (15.0%) cases were paediatric patients (<18 years old). All cases had both pre-septal and orbital fat involvement. The EOM were affected in nineteen cases, with the superior muscle complex (18/19, 94.7%) most commonly affected. Mean enlargement ratio (1.30, Range: 1.04-1.82) was greatest for the medial rectus on axial views on T1 and fat-suppressed contrast-enhanced T1 (FS CE T1). Optic peri-neuritis was present in eleven (55.0%) patients, whilst two (9.5%) cases had optic neuritis. A greater degree of proptosis was observed in patients with optic neuropathy and those who underwent surgical intervention compared to those without (p = .002 and p = .002, respectively). CONCLUSION: MRI remains an important imaging modality for evaluating complicated OC. However, qualitative features may lack accuracy and is not a reproducible means of analysis. Simple quantitative parameters, such as proptosis and EOM measurements, correlate with high-risk clinical features and may have utility in predicting clinical course.

Sarcoid-like reaction of the orbit in diffuse large B-cell lymphoma.

Sarcoid-like reaction (SLR) has been reported in patients with solid tumor malignancies, lymphomas, and patients receiving immunotherapy. SLR is often incidentally found during positron emission tomography/computed tomography scans as hilar and/or mediastinal lymphadenopathy. SLR has also been found in the lung, spleen, bone marrow, and skin. Biopsy of these lesions shows noncaseating granulomas. When systemic criteria are not met for sarcoidosis, these noncaseating granulomas are termed SLR. We present the first case in the literature of a case of orbital SLR in a patient with concomitant diffuse large B-cell lymphoma and inverted papilloma of the maxillary sinus. This case highlights the importance of including malignancy in the differential for the presence of a noncaseating granuloma in the orbit.

Ophthalmia neonatorum complicated with neonatal orbital cellulitis: A case series.

Orbital cellulitis is an extremely rare but potentially lethal condition in neonates. The clinical presentation of neonatal orbital cellulitis can be non-specific, and minimal signs of periorbital inflammation may go unrecognised by inexperienced parents or primary care medical personnel, leading to delayed treatment. Herein, we present a case series describing ophthalmia neonatorum complicated with neonatal orbital cellulitis owing to delayed treatment. The clinical presentation, management and outcomes are described. One neonate had orbital cellulitis, while the other had impending orbital cellulitis, with both cases resulting from delayed treatment of ophthalmia neonatorum. Both neonates were hospitalised for systemic antibiotic treatment and fully recovered with good outcomes. Timely identification and treatment of ophthalmia neonatorum are critical to mitigate potential severe sequelae, such as neonatal orbital cellulitis.

Pediatric preseptal and orbital cellulitis - a 6 year experience from a London tertiary centre.

PURPOSE: This study reports the experience of pediatric preseptal and orbital cellulitis at a London tertiary centre during a 6-year period and highlights the role of orbital surgeons in the management of subperiosteal abscess (SPA). METHODS: A retrospective review was conducted of all pediatric patients hospitalised for preseptal and orbital cellulitis. RESULTS: A total of 201 children including 152 cases of preseptal cellulitis and 49 cases of orbital cellulitis were admitted at a London tertiary centre over the study period. Patients with orbital cellulitis and especially those managed surgically had higher rates of fever, higher presenting white cell count and C-reactive protein level compared to cases of preseptal cellulitis. 77.6% of patients with orbital cellulitis had SPA. 81.6% of SPA had a medial component, while 28.9% had superior component. 61.2% of orbital cellulitis cases were managed surgically. Surgical intervention was carried out by otorhinolaryngologists (ENT) in 76.7% of cases, jointly between ENT and orbital surgeons in 16.7% of cases and by orbital surgeons alone in 6.7% of cases. Of the 11 SPA involving the orbital roof, all were surgically managed and orbital surgeons were involved in 54.5% of cases. When SPA involved the medial wall, orbital surgeons were only involved in 6.5% of cases. CONCLUSIONS: We recommend all patients with superior SPA be treated at a centre with both ENT and orbital surgeons as these may not be amenable to drainage by ENT alone.

Orbital abscess with white eye in patients treated with oral antibiotics for orbital cellulitis.

PURPOSE: To report a case series of seven patients with late presentation of orbital/subperiosteal abscess following oral treatment of orbital cellulitis. METHODS: A retrospective case series of all patients presented with orbital abscess following oral treatment of orbital cellulitis from two tertiary-care eye centres in Riyadh, Saudi Arabia, was conducted. Demographic profiles, risk factors, initial clinical presentation, management regimens, and final outcome were analysed. RESULTS: Patients presented mainly with proptosis and limitation of extraocular motility without external ophthalmic inflammatory signs. Most patients needed surgical evacuation despite the appropriate initiation of intravenous antibiotics following presentation to our hospitals. CONCLUSION: Treating orbital cellulitis with oral antibiotics may lead to delayed presentation of orbital abscess without external ophthalmic inflammatory signs.

Orbital Fat Density as a Diagnostic Tool in Pre-Septal and Orbital Cellulitis.

PURPOSE: To evaluate the usefulness of measuring orbital fat density in identifying post-septal involvement when initial differential diagnosis between orbital and periorbital cellulitis (OC and POC) is unclear. MATERIALS AND METHODS: Retrospective study of patients with clinical diagnosis of OC or POC who underwent contrast-enhanced computerized tomographic scans over a span of 10 years. Intraconal orbital fat density was measured with Hounsfield units (HU) in six areas on axial scans consisting of nasal and temporal intraconal sites. These measurements correlated with the initial and final diagnoses. Main outcome measures were HU values at the initial and final diagnoses. RESULTS: Fifty-seven patients were included. Mean HU measurement was -52 ± 18 HU for the involved side vs. -63 ± 13 for the uninvolved side (P < .001). The values were higher in cases of a final diagnosis of OC in the involved side (P < .001). The HU values were significantly higher in the nasal vs. the temporal locations of each orbit bilaterally (P < .001). The initial POC diagnosis of 20 patients (35%) was revised to OC. CONCLUSION: Intraconal fat density measurements can assist in the primary assessment of orbital involvement in patients with an uncertain initial diagnosis, with a HU value higher than -50 is suggestive of orbital involvement.

Role of Acute Rhinosinusitis in Periorbital Infections in Children.

OBJECTIVE: Periorbital cellulitis in children are commonly caused by acute rhinosinusitis (ARS). This study investigated the association of ARS and the severity of periorbital cellulitis in children. STUDY DESIGN: Retrospective case-control study of children with periorbital cellulitis with ARS versus periorbital cellulitis without ARS. SETTING: Patients were seen at West Virginia University Children's Hospitals between August 2011 to August 2022. METHODS: Patients were divided into cases and controls based on presence or absence of ARS. ARS was defined based on clinical symptoms with objective presence of disease on CT scan. Patients' characteristics, treatment, hospital length of stay, and readmission were collected. RESULTS: The sample consisted of 118 pediatric patients with orbital cellulitis. Patients with ARS were younger than patients without ARS (6.3 vs 8.5, p = 0.025), however there were no sex differences between two groups (p = 0.540). The ARS group had higher incidence of postseptal cellulitis (51.5% vs 9.6%, p < 0.001). As compared to patients without ARS, patients with ARS were more likely to be admitted (p < 0.001), have a longer length of stay (median of 3.5 days vs 0.5 days, p < 0.001), require IV antibiotics (95.3% vs 54.9%, p < 0.001), and require surgical intervention (23.1% vs 5.8%, p < 0.001). Readmission rate was similar between the two groups. CONCLUSION: Children presenting with acute periorbital cellulitis who have ARS tend to have more severe infection requiring higher level of care. ARS should be assessed and incorporated into the plan of care of pediatric patients with periorbital infections.

Visual outcomes following orbital decompression for orbital infections.

OBJECTIVE: To analyze the visual outcomes and sequelae of endonasal intervention for orbital infections. INTRODUCTION: Orbital infections pose a serious threat to vision in the pediatric population and can result in complications such as blindness, diplopia, intracranial involvement, and death. [1] Orbital decompression by endonasal intervention is a common treatment to address a variety of orbital infections including orbital cellulitis, orbital abscesses, and subperiosteal abscesses. [2] The outcomes of visual sequelae such as loss or limitation of visual acuity, extraocular movements, and increased intraocular pressure following orbital decompression via endonasal intervention have not been sufficiently investigated in the current literature. METHODS: This retrospective cohort study was performed at our tertiary care pediatric hospital using data from 69 patients aged 0-18 years who were admitted between 2008 and 2018. Data was extracted from the electronic medical record system. RESULTS: Following endoscopic sinus surgery, symptoms of orbital infection improved throughout the cohort. Improvement in visual acuity is demonstrated by a statistically significant decrease in the average logMAR value in both the right and left eye (P = 0.002 and P = 0.028 respectively). There was also a significant improvement to normal values postoperatively for patients who initially presented with abnormal tonometry, extraocular movement, and the appearance of eyelids and eyelashes. CONCLUSION: There is no decline or loss of vision with otolaryngology surgical intervention for orbital cellulitis in our cohort. This retrospective chart review demonstrates the efficacy of surgical intervention on overall visual outcomes following endonasal intervention for orbital infections such as orbital cellulitis, orbital abscesses, and subperiosteal abscesses.

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.

Orbital Onset: The Intricate Journey From Ear Abscess to Cavernous Sinus Thrombosis in a Diabetic Male.

Cavernous sinus thrombosis (CST) is a rare, yet severe condition often linked to infections in the nasal and facial areas. We present a case of a 43-year-old male farmer with diabetes who initially showed ear abscess symptoms that progressed to vision loss and CST-like symptoms. Self-treatment and an unidentified medication regimen may have worsened his condition. Advanced diagnostic evaluations, particularly magnetic resonance imaging with magnetic resonance venography, confirmed CST, likely originating from the ear infection spreading to the eyes, causing bilateral orbital cellulitis. Treatment with antibiotics, anticoagulants, and supportive therapy stabilized the patient's condition. This case emphasizes the importance of early detection and intervention in CST, especially in atypical presentations, and the need for comprehensive diagnostic and therapeutic approaches.

Carotid cavernous fistula masquerading as orbital cellulitis.

We report a case of direct carotid cavernous fistula (CCF) in a patient of head injury due to road traffic accident who presented several weeks after the injury with sudden onset of pain, redness, and proptosis of right eye. A 56 years old male patient with no known comorbidities presented to ophthalmology OPD with acute onset of pain, redness, swelling, and proptosis of right eye of one week duration and visual acuity of 1/60. Initially he was misdiagnosed and treated as orbital cellulitis. However, digital subtraction angiography confirmed the diagnosis of right direct CCF. Patient underwent endovascular treatment with a good visual recovery post operatively. Ophthalmologists should keep CCF higher up in their differential diagnosis of patients with red edematous eyes, especially with a history of trauma and get thorough investigations in order to provide timely aggressive management to such patients.

A rare case of orbital inflammation complicated by hemophagocytic lymphohistiocytosis.

We report a rare case of orbital inflammation complicating hemophagocytic lymphohistiocytosis (HLH) patient. HLH is a rare, life-threatening disorder characterized by uncontrolled activation of cytotoxic T lymphocytes, natural killer cells, and macrophages. A 37-year-old man known to have HLH, presented with a left periorbital swelling that was unsuccessfully treated as an orbital cellulitis, with intravenous antibiotics. A computed tomography (CT) scan of the orbits revealed inflammatory changes with no orbital collection or paranasal sinus disease. An orbital biopsy demonstrated lymphoplasmacytic infiltrations admixed with histiocytes. The patient deteriorated and was admitted to the intensive care unit. Ensuing blood results supported a diagnosis of HLH, and the patient responded well to subsequent immunosuppression. This case report highlights the importance of re-considering the diagnosis of orbital cellulitis in treatment resistant cases, particularly in the absence of sinus disease. To our knowledge, this is the third case of orbital inflammation associated with HLH patients.

Combined upper lid skin crease and endoscopic approach to frontal sinus mucocoeles.

PURPOSE: This case series describes the ophthalmic manifestations of frontal sinus mucoceles and reports the long-term surgical outcomes of a combined endoscopic and upper-lid skin crease drainage approach carried out jointly with otorhinolaryngology. METHODS: We present a retrospective case review of 18 orbits and 15 patients presenting with frontal sinus mucocoeles, all of whom underwent drainage via an adapted anterior orbitotomy approach between January 2015 and July 2023. Data collection included preoperative and postoperative examination findings (visual acuity, extraocular motility, lid retraction, and lagophthalmos), mucocoele recurrence, cosmetic satisfaction, and surgical complications. Patients were followed up for an average of 22 months. RESULTS: All patients underwent successful frontal mucocoele drainage via a modified anterior orbitotomy and simultaneous endonasal approach. At presentation, three (20%) had extraocular restriction leading to diplopia, and six (40%) had proptosis in the eye adjacent to the mucocoele. One patient presented acutely with no light perception in the affected eye due to compressive optic neuropathy. All patients who had reduced extraocular motility before surgery regained full motility post-operatively. Treatment was successful in all cases, and there was no documented mucocoele recurrence during follow-up. Satisfactory aesthetic outcomes were achieved in all cases. Reported complications included temporary forehead numbness and ptosis of the affected eyelid, which resolved without intervention. CONCLUSION: The modified anterior orbitotomy approach to frontal mucocoeles allows optimal frontal sinus access and mucocoele treatment while preserving cosmesis.

A multidisciplinary approach to frontal sinus mucocoeles using an upper lid skin crease incision combined with endoscopic drainage allows full access to the frontal sinus and treatment of the mucocoele while preserving cosmesis.

Orbital Osteomyelitis and Periorbital Abscess Due to Coccidioidomycosis Following Trauma.

Ocular involvement due to Coccidioides sp.is extremely rare, and most patients with disseminated coccidioidomycosis present as extrapulmonary or disseminated disease that involves the skin, bone joints, and central nervous system. Here, we describe a 13-year-old previously healthy Black male residing in an area endemic for coccidioidomycosis. The child presented to our hospital with left eye pain, diplopia, and proptosis two weeks after being struck on the left side of the face with a basketball. He was initially presumed to have bacterial orbital cellulitis and was started on empiric antibiotics. Due to severe disease, he underwent surgical drainage and debridement. Fungal stain from the intraoperative specimen showed spherules with endosporulation, and fungal culture revealed Coccidioides immitis. Based on this, the child was diagnosed with orbital osteomyelitis and periorbital abscess due to coccidioidomycosis. He was started on intravenous liposomal amphotericin B and fluconazole. Antibiotics were discontinued. He underwent additional investigations to assess for sites of dissemination. His nuclear medicine bone scintigraphy and cerebrospinal fluid studies were negative. A computed tomography (CT) scan of the chest demonstrated multiple small pulmonary nodules. His Coccidioides complement fixation(CF) titer was 1:32. The patient completed one month of treatment with liposomal amphotericin B and fluconazole. Our case highlights the need for healthcare professionals to consider coccidioidomycosis when evaluating patients with orbital disease as delays in the diagnosis may result in visual loss and central nervous system involvement. Prompt diagnosis, evaluation, and treatment are crucial to reduce long-term morbidity and mortality.

Pediatric Acute Dacryocystitis and Orbital Cellulitis With Concurrent COVID-19 Infection: A Case Report.

Acute dacryocystitis and orbital cellulitis are conditions with serious implications, particularly among pediatric patients. The co-occurrence of these conditions in children is rare, and their association with coronavirus disease 2019 (COVID-19) infection introduces a unique dimension. We present the case of a five-year-old boy who presented to the pediatric emergency department with left periorbital swelling, erythema, and excessive tearing. He had a history of low-grade fever and rhinorrhea, raising concerns about COVID-19. Upon physical examination, we observed significant periorbital swelling and erythema, accompanied by conjunctival injection and chemosis. The diagnosis encompassed acute dacryocystitis and cellulitis, with subsequent confirmation of COVID-19 through testing. Imaging confirmed the presence of post-septal cellulitis and ethmoid sinus opacification. The patient received intravenous antibiotics, leading to clinical improvement and eventual discharge for outpatient follow-up. This case underscores the importance of maintaining a high index of suspicion for unusual presentations in pediatric patients. Successful management involved a multidisciplinary approach, emphasizing the significance of promptly initiating antibiotic therapy and adopting conservative measures for nasolacrimal duct obstruction.

Orbital cellulitis with panophthalmitis and scleral necrosis - a case report.

BACKGROUND: Orbital cellulitis is common in young children and is often secondary to coexisting sinus disease. Coexisting orbital cellulitis and panophthalmitis is a rare clinical event and usually occurs secondary to trauma or from an endogenous source. CASE PRESENTATION: A febrile 2-year-old male presented with periorbital inflammation and exudative retinal detachment. Imaging showed acute sinusitis and extensive orbital cellulitis. Because of progressive scleral thinning, the patient underwent enucleation. CONCLUSION: We present a case of concurrent orbital cellulitis, panophthalmitis, and scleral necrosis in an immunocompetent pediatric patient. Timely intervention is important to prevent life threatening complications with the rare occurrence of coexistent orbital cellulitis and panophthalmitis.

A Rare Occurrence of Isolated Endogenous Escherichia coli Panophthalmitis: A Case Report.

Panophthalmitis is a severe ocular condition that can lead to devastating outcomes, such as evisceration, if not promptly treated. It typically originates endogenously, with urinary tract infection being a common primary source of infection. This report describes a rare case of a 61-year-old Malay patient with left eye panophthalmitis. Ocular culture revealed Escherichia coli, while systemic septic workup yielded negative results. Due to the severity of the ocular condition at presentation and the disproportionate level of pain the patient had, an immunocompromised state was suspected and later the diagnosis of diabetes mellitus was confirmed via laboratory investigation. Despite the delay in presentation, which hindered early intervention, the patient's eyeball was successfully salvaged through a treatment regimen involving three injections of intravitreal antibiotic administered at 48 to 72-hour intervals and a complete course of intravenous antibiotics. This case report highlights the importance of prompt treatment to salvage an eye from evisceration in the case of panophthalmitis.