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Clinical Characteristics and Outcomes of Paediatric Orbital Cellulitis in Hospital Universiti Sains Malaysia: a Five-Year Review

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Clinical Characteristics and Outcomes of Paediatric Orbital Cellulitis in Hospital Universiti Sains Malaysia: a Five-Year Review Singapore Med J 2020; 61(6): 312-319 Original Article https://doi.org/10.11622/smedj.2019121 Clinical characteristics and outcomes of paediatric orbital cellulitis in Hospital Universiti Sains Malaysia: a five-year review Ismail Mohd-Ilham1,2, MBBS, MMed, Abd Bari Muhd-Syafi1,2, MBBS, Sonny Teo Khairy-Shamel1,2, MD, MMed, Ismail Shatriah1,2, MD, MMed INTRODUCTION Limited data is available on paediatric orbital cellulitis in Asia. We aimed to describe demographic data, clinical presentation, predisposing factors, identified microorganisms, choice of antibiotics and management in children with orbital cellulitis treated in a tertiary care centre in Malaysia. METHODS A retrospective review was performed on children with orbital cellulitis aged below 18 years who were admitted to Hospital Universiti Sains Malaysia, Kelantan, Malaysia, between January 2013 and December 2017. RESULTS A total of 14 paediatric patients fulfilling the diagnostic criteria for orbital cellulitis were included. Their mean age was 6.5 ± 1.2 years. Boys were more likely to have orbital cellulitis than girls (71.4% vs. 28.6%). Involvement of both eyes was observed in 14.3% of the patients. Sinusitis (28.6%) and upper respiratory tract infection (21.4%) were the most common predisposing causes. Staphylococcus aureus (28.6%) was the leading pathogen. Longer duration of hospitalisation was observed in those infected with methicillin-resistant Staphylococcus aureus and Burkholderia pseudomallei. 10 (71.4%) patients were treated with a combination of two or three antibiotics. In this series, 42.9% had surgical interventions. CONCLUSION Young boys were found to be more commonly affected by orbital cellulitis than young girls. Staphylococcus aureus was the most common isolated microorganism. Methicillin-resistant Staphylococcus aureus and Burkholderia pseudomallei caused severe infection. Sinusitis and upper respiratory tract infection were the most common predisposing factors. A majority of the children improved with medical treatment alone. Our findings are in slight disagreement with other published reports on paediatric orbital cellulitis, especially from the Asian region. Keywords: Asian children, orbital abscess, orbital cellulitis INTRODUCTION Cases were identified through a database search of medical Orbital cellulitis in children is a serious infection that can result records using the International Classification of Diseases Ninth in significant complications including blindness, cavernous sinus and Tenth Revision codes (376.01, H05.0) for orbital cellulitis. A thrombosis, meningitis, subdural empyema and brain abscess.(1-3) total of 44 paediatric patients with the diagnosis of orbital cellulitis Prompt diagnosis and early treatment are important to prevent were identified on the admission computers, and their medical potential vision or life-threatening conditions. records were retrieved. Children who were diagnosed with orbital Numerous reports on paediatric orbital cellulitis have cellulitis and admitted to the ward were included in our study. been published in the literature.(4-12) Despite the abundance We excluded those who had pre-existing ocular diseases such as of reports on the topic, among Asian countries, data was only corneal opacity, congenital cataracts, strabismus, refractive errors, available from Singapore, India and Taiwan.(12-15) These series optic disc or macular problems. A final list was reviewed, and 14 included data on both adults and children.(13-15) In this study, patients were carefully selected. Data documented included age, we described demographics, clinical characteristics, causative gender, laterality, possible identified cause of infection, presenting organisms, treatment and visual outcomes among paediatric clinical manifestations, imaging results, microbiology results, orbital cellulitis cases treated in Malaysia, and reviewed the treatment options (medical treatment alone or in combination relevant literature. with surgical drainage), length of hospital stay and final visual outcome. The institution required patients’ paediatric orbital METHODS cellulitis registry forms to be completed by a consultant paediatric A retrospective case series was conducted on all children aged ophthalmologist. Data was analysed using SPSS Statistics version under 18 years who were diagnosed with orbital cellulitis 22.0 (IBM Corp, Armonk, NY, USA). and admitted to Hospital Universiti Sains Malaysia, Kelantan, Malaysia. Data was collected from 1 January 2013 till 31 RESULTS December 2017. The study was conducted in accordance with A total of 14 paediatric patients with orbital cellulitis in 16 eyes the Declaration of Helsinki. were recruited according to the study protocol. Table I summarises 1Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 2Hospital Universiti Sains Malaysia, Kelantan, Malaysia Correspondence: Dr Ismail Shatriah, Consultant Paediatric Ophthalmologist, Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia. [email protected] 312 Original Article Table I. Summary of clinical cases (n = 14). No. Age; Clinical presentation; CT result Cause Culture; investigation Antibiotic (duration) Surgery Hospital LOS Presenting gender onset; laterality VA; final VA 1 6 yr; M Lid swelling, ptosis, Extraconal abscess Upper respiratory No growth from eye swab, IV ceftriaxone (1 wk), Nil 12 days 6/6; 6/6 high-grade fever; 3 days; (subperiosteal tract infection and blood and urine samples; IV Augmentin (5 days) right eye abscess) sinusitis TWC 10.6, PLT 383, ESR 96, CRP NA 2 5 yr; M Lid swelling, erythema, Lid and cerebral Trauma – hit by No growth from pus, IV ceftriaxone Open lid incision 7 wk Not ptosis, high-grade fever, abscess toys, underlying blood and urine samples; (7 wk), IV and drainage cooperative; intracranial abscess; sinusitis TWC 14.7, PLT 444, ESR metronidazole 6/6 7 days; left eye 106, CRP positive (6 wk) 3 2 yr; M Lid swelling, ptosis, Medial canthus Upper respiratory Streptococcus pneumoniae IV Augmentin Nil 1 wk NA; NA chemosis, high-grade abscess tract infection (pus); TWC 19.6, PLT 271, (5 days), IV cloxacillin fever; 2 days; both eyes and exudative ESR NA, CRP positive (5 days) tonsillopharyngitis 4 6 yr; M Lid swelling, ptosis, Lid abscess No identified No growth from eye swab, IV Augmentin Nil 5 days 6/9; 6/6 chemosis; 1 day; right cause blood and urine samples; (5 days) eye TWC NA, ESR NA, CRP NA 5 14 yr; M Lid swelling, ptosis, Periorbital tissue Trauma and Streptococcus beta- IV ceftriaxone Open lid incision 2 wk 6/6; 6/6 chemosis, low-grade thickening laceration wound haemolytic group A; (2 wk), IV cloxacillin and drainage fever; 1 day; right eye extending to right at the temporal Staphyloccus aureus (pus); (2 wk) temporal region eyelid TWC 32.6, PLT 150, ESR NA, CRP NA 6 13 yr; M Lid swelling, chemosis, Not done Upper respiratory No growth from eye swab, IV Augmentin Nil 6 days 6/12; 6/6 low-grade fever; 5 days; tract infection blood and urine samples; (5 days) right eye TWC 7.6, PLT 206, ESR NA, CRP NA 7 39 days; Facial swelling, proptosis, Periorbital and Gingivostomatitis Methicillin-resistant IV ceftazidime Image-guided 23 days NA; NA M chemosis, high-grade facial abscess Staphylococous aureus (14 days), IV endoscopic fever; 1 day; right eye (from eye swab and blood metronidazole drainage sample); TWC 13.4, PLT (14 days), IV 511, ESR NA, CRP positive vancomycin (10 days) 8 10 yr; F Lid swelling, chemosis, Soft tissue Dacryocystitis No growth from eye swab, IV Augmentin Nil 11 days 6/6; 6/6 high-grade fever; 3 days; thickening and blood and urine samples; (5 days), IV left eye lacrimal sac abscess TWC 12.01, PLT 270, ESR ceftazidime (1 wk), IV NA, CRP NA metronidazole (1 wk) 9 6 yr; M Lid swelling, chemosis, Lid abscess and Pansinusitis No growth from eye swab, IV Augmentin Nasal decongestion 8 days Not ophthalmoplegia, low- orbital cellulitis blood and urine samples; (5 days), IV ceftazidime and left antral cooperative; grade fever; 1 day; left eye TWC 29.7, PLT 896, ESR (5 days), IV washout 6/9 NA, CRP NA metronidazole (5 days) 10 11 yr; F Lid swelling, chemosis, Not done Infected wound Staphylococcus aureus IV Augmentin Nil 7 days 6/21; 6/6 no fever; 7 days; left eye from a ruptured (pus); TWC 9.9, PLT 263, (5 days) upper lid abscess ESR NA, CRP NA (Contd...) 313 Original Article 314 Table I. (Contd...) No. Age; Clinical presentation; CT result Cause Culture; investigation Antibiotic (duration) Surgery Hospital LOS Presenting gender onset; laterality VA; final VA 11 4 yr; M Lid swelling, chemosis, Heterogeneous Dacryoadenitis No growth from eye swab, IV Augmentin Nil 16 days 6/12; 6/6 low-grade fever; 4 days; enhancement of blood and urine samples; (1 wk), IV ceftazidime left eye anterior orbital tissue TWC 10.4, PLT 225, ESR (1 wk), IV with fluid collection NA, CRP NA metronidazole (1 wk) 12 1 yr; M Lid swelling, chemosis, Soft tissue No identified No growth from eye swab, IV Augmentin Open eyelid incision 7 days NA; NA ptosis; 3 days; left eye thickening cause blood and urine samples; (1 wk) and drainage TWC 8.4, PLT 276, ESR NA, CRP negative 13 7 yr; F Lid swelling, chemosis, Enhancing soft tissue Sinusitis and Staphylococcus aureus IV ceftriaxone Nil 9 days 6/12; 6/6 proptosis, ophthalmoplegia, thickening with dacryoadenitis (pus); TWC 12.1, PLT 242, (1 wk) diplopia; 3 days; left eye intraorbital abscess ESR 18, CRP NA 14 11 yr; F Periorbital swelling, Bilateral orbital No identified Burkholderia pseudomallei; IV ceftazidime Bifrontal craniotomy 49 days 6/60; 6/6 blurred vision, proptosis, abscess, intracranial cause TWC NA, PLT NA, ESR NA, (6 wk), IV and evacuation of ophthalmoplegia, abscess, subdural CRP NA metronidazole pus within subdural high-grade fever, empyema and (6 wk) space, open eyelid intracranial abscess; cavernous sinus incision and 3 days; both eyes thrombosis drainage CRP: C-reactive protein; CT: computed tomography; ESR: erythrocyte sedimentation rate; F: female; IV: intravenous; LOS: length of stay; M: male; NA: not applicable; PLT: platelet count; TWC: total white cell count; VA: visual acuity as wellAtfeh andKhalil(4.0%).
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