Healthy Baby Practical advice for treating newborns and toddlers.

Getting an Eyeful of Preseptal Stan L. Block, MD, FAAP

ractitioners are often confronted with the mildly to moderately ill P child who presents with an area of distinct redness and/or swelling of the skin around the . This is often accompanied by purulent conjunctival discharge, fever, purulent rhinorrhea, or concomitant acute otitis media. You must then decide whether this is preseptal cel- lulitis (peri-orbital cellulitis), orbital cel- lulitis, an allergic reaction, sec- Images courtesy of Stan L. Block, MD, FAAP. Figure 1. An 8-month-old white boy with an upper respiratory infection for the past week has now de- ondary to trauma, contact dermatitis, or veloped moderate swelling and redness of his right upper eyelid in the last 24 hours, along with a fever the result of eye rubbing. You must also of 102.4°F, crankiness, and ear tugging. perform a thorough physical examina- otitis media (AOM). Specific manage- evaluation is needed. If the child has a tion, particularly evaluating the child’s ment options are addressed in the fol- concomitant purulent , I level of toxicity, and the tympanic mem- lowing cases. prefer to obtain an eye culture, particu- branes, pharynx, lungs, and skin. PC must be differentiated from the larly if the child has an associated AOM Preseptal cellulitis (PC) is an infec- very serious infection, orbital cellulitis, because of the high pathogen correlation tion of the skin surrounding the eyelid which usually involves an osteomyelitis between AOM and conjunctivitis.1 For that is localized anterior to the orbital and invasion of the orbital bones. The cases of PC, this also may provide valu- septum — a thin layer of fascia that cardinal features of orbital cellulitis are able (and the only) information as to the provides a barrier to deeper invasion by proptosis, , olphthalmoplegia, etiology and pathogen susceptibilities, infectious agents. The typical signs of visual loss, and restricted ocular mobil- especially if the recovered pathogen is PC are erythema, edema, and pain of ity. Immediate hospitalization, comput- , Staphylo- the eyelid(s). It is usually unilateral, and ed tomography (CT) scan of the , coccus aureus, or Streptococcus pyo- may be associated with fever and acute and ophthalmologic referral is essential. genes. However, some experts consider Rarely, the swelling of the skin around an eye culture in PC to provide minimal Stan L. Block, MD, FAAP, is Professor of Clinical the eyelid in PC may be so severe that information.2 Pediatrics, University of Louisville, and University of a complete examination of the for Aspiration of the leading edge of the Kentucky, Lexington, KY; President, Kentucky Pedi- signs of orbital cellulitis may be difficult cellulitis rarely ever recovers a pathogen atric and Adult Research Inc.; and general pediatri- or impossible, thus requiring CT imag- and is not advocated. I typically consider cian, Bardstown, KY. ing of the globe (similar to Figure 1). obtaining a (CBC) Address correspondence to Stan L. Block, MD, in any child with PC who has actual fe- FAAP, via email: [email protected]. DIAGNOSTIC EVALUATION OF ver, moderate to severe PC, and who is Disclosure: Dr. Block has no relevant financial PRESEPTAL CELLULITIS younger than 24 months. , relationships to disclose. In most cases of children with mild although rarely positive, and even hospi- doi: 10.3928/00904481-20130222-05 PC and no or low-grade fever, no further talization, should be considered in most

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children with PC who are unvaccinated; are highly febrile; are toxic appearing; have profound neutrophilic leukocyto- sis (> 20,000 cells/mm3); or are younger than 2 months. A few days of ceftriaxone injections with careful daily follow-up may be an alternative approach in the nontoxic child outside the newborn period who has nontraumatic PC. The majority of children with nonsevere PC can be man- Figure 2. A 16-month-old white male pesented with 48 hours of rhinorrhea, low-grade fever, crankiness, aged as an outpatient with oral antibiot- and discharge from both eyes (worse on the right). He was still taking his amoxicillin twice daily from ics. Antibiotic selection is guided by the an epsiode of right acute otitis media 1 week prior, when he developed a cellulitis of the right lower assessment of the following etiologies of eyelid area. PC. CT scan of the orbit and ophthalmic except in those families who still refuse two sinuses are normally aerated and referral is typically only necessary for HIB vaccines for their infant. You should functional after birth.) His leukocyte those in whom orbital cellulitis is a diag- consider hospitalization for any infant count is elevated (white blood cell = nostic possibility. who looks toxic, or who is unvaccinated 18,500 cells/mm3). with a fever, Because he is nontoxic, the mother is ETIOLOGY OF quite reliable, and the most likely caus- PRESEPTAL CELLULITIS Posttraumatic Spread ative pathogen is S. pneumoniae, you Localized Spread PC can arise from either penetrating prescribe oral high-dose amoxicillin- PC can result from contiguous spread trauma, such as an animal bite or lac- clavulanate (90 mg/kg/day) twice daily of bacterial infection in the , eration, or direct blunt force. The most for 10 days. Follow-up the next morn- adjacent sinuses, or lacrimal duct/horde- common pathogens of these two sourc- ing reveals a marked resolution of his olum (see Figure 1, page 99; and Figure es, respectively, would be Pasteurella systemic symptoms, fever and cellulitis. 2) The causative bacterial pathogens of multocida/S. aureus/streptococcal spe- the former two infections are the typical cies versus S. aureus/S. pyogenes. With Case 2 otopathogens of AOM: S. pneumoniae; blunt force trauma, you should be most A 16-month-old white boy presented occasionally nontypeable Haemophilus concerned with the possibility of methi- with symptoms of an upper respiratory influenzae; and rarely Group A strepto- cillin-resistant S. aureus (MRSA), which infection (URI) for 2 weeks, and a puru- coccus or Moraxella catarrhalis. Infec- may be as high as 60% to 75% in many lent conjunctivitis for several days. He tions of the lacrimal duct/hordeolum areas of the US.2 was prescribed amoxicillin twice daily tend to be S. aureus, and only occasion- for AOM last week, which he is still tak- ally, otopthogens. CASES OF PRESEPTAL CELLULITIS ing at today’s visit. Today, he developed Case 1 a mild PC of the right lower eyelid (see Hematogenous Spread The 8-month-old white boy in Fig- Figure 2) and his AOM remains unre- Currently, the pathogen of pediatric ure 1 (see page 99) has a moderate solved. Aside from the temperature of bacteremia in healthy children is nearly upper eyelid PC without purulent con- 100ºF, mild peri-oral facial rash, and always S. pneumoniae, which may dis- junctivitis. This degree of orbital edema purulent rhinorrhea, his physical ex- seminate from the bloodstream into the requires careful evaluation. You feel amination is unremarkable. You obtain periorbital tissue. The recent universal comfortable that his right eye is able to a routine bacterial culture of the right implementation of pneumococcal conju- track your penlight laterally and verti- eye discharge and CBC, which shows gate vaccine (PCV13) is likely continu- cally without any pain, and that he has a leukocyte count of 12,550 cells/mm3. ing to reduce the overall incidence of he- no chemosis or proptosis. Upon exami- You know that the most common cause matogenous invasive pneumococcal PC. nation, he also has concomitant AOM of simultaneous purulent acute conjunc- Although Haemophilus influenzae type and significant purulent rhinorrhea. tivitis and AOM is non typeable H. in- B (HIB) was a common pathogen in the The etiology of his PC is most likely a fluenzae, which is most commonly beta 1970s, the universal use of HIB vaccine secondary localized extension from his lactamase positive.1 This could account has virtually eliminated HIB infections, maxillary or ethmoid sinuses (These for his lack of response to amoxicillin.

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Because he is fully vaccinated with PCV13 and HIB vaccine, typical of all children attending your practice, you think that resistant pneumococcus is un- likely, and you have not seen more than one case of HIB invasive disease in two decades. He is nontoxic and afebrile, his leukocyte count is within normal range, and he has an infection which highly suggests nontypeable H. influenzae. You thus prescribe once daily cefdinir as one Figure 3. A 6-year-old white girl has had rhinorrhea and cough for 3 days. She developed redness and of two formulary based options (the oth- tenderness of the left lower eyelid on the third day. er being twice daily amoxicillin-clavu- lanate) with reasonable beta lactamase- stable activity. Upon follow-up the next day, his PC has markedly improved and his de- meanor is much better. Three days later, his eye culture grows beta lactamase- negative H. influenzae, which appears to be one of those increasingly com- mon beta lactamase negative ampicil- Figure 4. A 7-year-old white boy who has had rhinorrhea for 5 days and a hordeolum on right upper lin resistant (BLNAR) strains described eyelid for 2 days. He was hit by a softball over the right zygoma/lateral orbit 2 days ago as well. His recently.2,3 Fortunately, the cefdinir was physical examination also reveals a right acute otitis media and right upper eyelid swelling and redness. working well despite the alterations in therapy specifically towards pneumo- right tympanic membrane full of yellow penicillin binding proteins common to coccal infection. She does not look ill pus, and a swollen erythematous right BLNAR strains. enough to warrant a blood culture, thus upper eyelid. Once you are able to gen- no cultures will be available later to tly pry the right eyelid open you can see Case 3 guide therapy. You prescribe twice dai- that he has no chemosis or proptosis, A 6-year-old white girl presents in ly amoxicillin at 50 mg/kg/day, aware and that he can easily track your pen- your office with a 3-day history of URI that the use of high dose 90 mg/kg/day light laterally and horizontally without and an acute onset of left periorbital becomes almost prohibitive in a 25 kg pain. You also note that his vision is nor- edema and lower lid redness today (see child (over 1 gram per dose of amoxi- mal, but obtaining a decent fundoscopic Figure 3). She has a fever of 101ºF; her cillin). At the important follow-up visit examination of his eye is impossible tympanic membranes, conjunctiva, and after 24 hours, she has responded well due to his discomfort. However he does pharynx are normal; the remainder of her to your therapy. Thus you do not need to not complain of any or other physical examination is unremarkable. consider treating her with parenteral cef- visual field defects. He is afebrile, non- Her left eye has no chemosis, proptosis, triaxone for clinical failure suspicious of toxic but feels poorly, and the remainder ophthalmoplegia or visual loss. She is resistant pneumococcus etiology. of his physical examination is normal. nontoxic, and you have ordered a CBC You obtain a CBC which is normal. He which shows a slightly elevated leuko- Case 4 is fully vaccinated with HIB and PCV7. cyte count of 16,800 cells/mm3. She has A 7-year-old white boy presents with Antibiotic selection is quite problem- been fully vaccinated with both HIB vac- a history of having had rhinorrhea for atic for you. You will have no cultures to cine and PCV7 (not PCV13), so that pen- 5 days, an untreated right upper eyelid potentially guide you either. Traumatic icillin resistant pneumococcal strains of hordeolum for 2 days, and a traumatic PC is most commonly caused by S. aure- 19A and 6A/C may be possible. Because contusion from a softball onto the right us, especially in light of his hordeolum, of her older age and lack of concomi- zygoma/eyelid also from 2 days ago (see for which you would normally prescribe tant AOM, non-typeable H. influenzae is Figure 4). In addition, his right ear has either or trimethorpim-sul- much less probable. been hurting for 2 days. famethoxazole to cover for the high like- Thus you wish to target antibiotic His physical examination reveals a lihood of MRSA. But neither antibiotic

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has reasonably broad AOM coverage, did not improve within the next 24 to 48 erate PC will not require CT scanning of particularly for H. influenzae. Nontrau- hours. Then you would consider either the orbit to assess for the highly serious matic PC at this older age is most fre- hospitalization for parenteral antibiot- infection of orbital cellulitis. Antibiotic quently associated with pneumococ- ics, or outpatient management with con- selection for PC is often complicated by cus. However, AOM is most commonly comitant intramuscular ceftriaxone and real life presentations, additional con- caused by both pneumococcus and non- oral clindamycin — if he was still not ill comitant infections, taste issues, and typeable H. influenzae, even at this age. appearing and his leukocyte count were social issues. Because he has reliable vigilant par- stable. Fortunately, your double oral an- ents, you elect to use two different oral tibiotic gambit pays off, and he is much REFERENCES antibiotics to supplement the pathogen improved the next day at follow-up. 1. Block SL. Etiologic and therapeutic pit- falls of newborn conjunctivitis. Pediatr Ann. weakness coverage, respectively. You 2012;41(8):310-313. prescribe the slightly more palatable CONCLUSION 2. Feigin RD, Cherry J, Demmler-Harrison GJ, twice-daily trimethoprim sulfamethoxa- In fully vaccinated children, some of Kaplan SL (eds). Feigin and Cherry’s Text- zole (for MRSA), and the once-daily cef- the caveats to your outpatient approach book of Pediatric Infectious Diseases. 6th edition. Philadelphia, PA: Saunders Elsevier; dinir (for pneumococcus and nontypeable to children with PC require reliable pa- 2009. H. influenzae). This should help limit rental vigilance and office access over 3. Block SL. Management of acute otitis media in palatability issues, diarrhea issues (as- the next several days; the ability to fully afebrile infants. Pediatr Ann. 2012;41(6):225- 228. sociated with amoxicillin-clavulanate), assess the eye for chemosis, proptosis, 4. AAP Committee on Infectious Diseases; Pick- MRSA clindamycin resistance (up to ophthalmoplegia, and intact extra ocu- ering LK, Baker CJ, Kimberlin DW, Long SS 20%)4 and heightened concerns of anti- lar movements — particularly in cases (eds). Red Book: 2012. Report of the Commit- tee on Infectious Diseases (Red Book Report biotic-induced colitis (with clindamycin). of notable eyelid edema or younger age. of the Committee on Infectious Diseases). Your next concern would be resistant With careful and thorough ocular ex- 29th edition. Elk Grove Village, IL. American pneumococcus and MRSA failure if he aminations, most cases of mild to mod- Academy of Pediatrics; 2012.

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