I. Case History

Patient demographics -A 50- year old White male veteran Chief complaint - Increasing redness and swelling of superior and inferior right with overlying abscess that first started 1 week ago -Recent diagnosis of a recurrent sebaceous cyst of the upper right warm -Expressed the cyst last night – white/green discharge with a strong odor Ocular, medical history -History of a sebaceous cyst of right eyelid that have been surgically drained without complication in 2011 -History of extraction and IOL implant in both eyes without complications over 1 year ago -Recent hospitalization for pneumonia -Has elevated liver enzymes, chronic obstructive pulmonary disease, vitamin D deficiency and alcoholism Medications Current: -Augmentin (Amoxicillin 875 mg/Clavulanic Acid 125 mg) BID PO -Has been taking for 3 weeks -Cholecalciferol 1,0000 I.U -Albuterol 90 mcg inhaler -Tiotropium 18 mcg inhaler -Tramadol 50mg Recent Discontinued: -Azithromycin 250 mg BID for 4 days – discontinued and Augmentin was immediately initiated -Moxifloxacin HCl 400 mg for 10 days – discontinued and Azithromycin was immediately initiated

II. Pertinent findings

Clinical -Diffuse grade 4 periorbital edema of superior and inferior eyelid Redness -Open abscess on superior right eyelid -Denied symptoms of /negative clinical signs: Pain on eye movement Proptosis RAPD Reduced vision Recent

Physical N/A

Laboratory studies Wound Culture: -staphylococcus coagulase negative, however, inconclusive, due to a low quantity of specimen with probable indigenous microbiota or contaminant

Radiology studies CT Scan of with and without contrast: Findings consistent with a right-sided preseptal with small abscess formation without progression to intraorbital/postseptal cellulitis Others Creatinine value: 0.37

III. Differential diagnosis Primary/leading -Pre-Septal cellulitis secondary to infectious sebaceous cyst with the offending agent being MRSA Others - secondary to infectious sebaceous cyst with the offending agent being MRSA

IV. Diagnosis and discussion

Elaborate on the condition - An of the underlying tissue of the eyelid anterior to the - Can result from direct inoculation of a pathogen after a traumatic event, spreading of a localized infection, nasolacrimal duct obstruction, dental abscesses and ethmoid or maxillary sinusitis -Marked unilateral swelling, redness, warmth and tenderness of the eyelid with or without an overlying wound -Must rule out orbital cellulitis: diplopia, pain on eye movement, unilateral proptosis, decreased vision, impaired pupillary response, severe malaise and fever and dysfunction -Target Gram positive bacteria and H. influenza. Augmentin (amoxicillin and clavulanic acid); allergic to penicillins, a good alternative is Bactrim DS (sulfamethoxazole and trimethoprim) -If initial oral treatment fails, intravenous vancomycin is an effective choice

Expound on unique features - condition worsening while being on Augmentin as well as recent hospitalization were red flags for bacterial resistance/MRSA -case prompted increased aggression in treatment and management as secondary orbital cellulitis can result from untreated or mismanaged pre-septal cellulitis -Importance of interdisciplinary management with clinical pharmacist and internist

V. Treatment, management

Treatment and response to treatment

Day 1: admitted patient to VA hospital -Started patient on IV Vancomycin 1gram Q8H started same day as eye examination -In sodium chloride 0.9% injection, solution 250 mL infuse over 90 minutes -Creatinine value: 0.37 -Started patient on Poly Bak ophthalmic ointment QID to apply to overlying abscess

Day 2: -Received only two doses of IV Vancomycin 1gram -Trough drawn: 15.4 *must repeat trough as vancomycin has not reached it’s steady state -Creatinine value: 0.37 -Receiving appropriate QID dosage of Poly Bak ophthalmic ointment -Patient presents to clinic with marked decrease in periorbital edema and redness, overlying abscess has not changed.

Day 3: -Received 5 doses of IV Vancomycin 1gram -Trough drawn: 20.7 -Receiving QID dosage of Poly Bak ophthalmic ointment -Did not see patient in clinic as this was over the weekend

Day 4: -Received 11 doses of IV Vancomycin 1gram Q8H -Creatinine value: 0.57 -Receiving QID dosage of Poly Bak ophthalmic ointment -Patient presents to clinic with mostly resolved periorbital edema and redness, overlying abscess mostly resolved as a small scab -Discharged from hospital and put on oral Clindamycin 300 mg for a 15 day course and continue the Poly Bak ophthalmic ointment until 2 week follow up

Day 18: 2 week follow up -Patient presents complete resolution of condition and abscess with now quiet sebaceous cyst of upper right eyelid -Properly applying Poly Bak antibiotic ointment and is finishing course of Clindamycin -Referred to oculo-plastic surgeon for excision of recurrent sebaceous cyst -Follow up PRN

VI. Conclusion

Clinical pearls

-It is imperative to take a good case history including recent or current medications, especially antibiotics as well as recent hospitalization. -Pre-septal cellulitis should be treated aggressively because the risk of the infection becoming orbital cellulitis increases with ineffective treatment. -Conservative medical practice is important when the clinician is unsure of orbital involvement. A CT scan can be ordered. Additionally, ordering a wound culture when appropriate is practicing effective and efficient medicine. -The creatinine value is important when determining kidney function. A normal range is 0.6mg/dL to 1.2 mg/dL. Vancomycin, even in the presence of healthy, functional kidneys, can cause acute iatrogenic kidney failure. The creatinine value in presence of kidney malfunction would be above 3mg/dL. - Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A typical trough for effective treatment would be 10-20 mg/L.

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