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Title: up to Nose Good: Periorbital Recalcitrant Impetigo Roberto Saenz OD MS, D’Laine Pulliam OD, Thomas Nettleton OD, Jill Autry OD, Young Mcmahan MD

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Title: up to Nose Good: Periorbital Recalcitrant Impetigo Roberto Saenz OD MS, D’Laine Pulliam OD, Thomas Nettleton OD, Jill Autry OD, Young Mcmahan MD Title: Up to Nose Good: Periorbital Recalcitrant Impetigo Roberto Saenz OD MS, D’laine Pulliam OD, Thomas Nettleton OD, Jill Autry OD, Young McMahan MD Abstract (35 words and present tense) A 15-year-old Hispanic male, undergoing unsuccessful treatment for the past month, presents with painful, itchy eyelids. His diagnosis is periorbital impetigo and a secondary bacterial conjunctivitis. I. Case History A 15-year-old Hispanic male presented to the clinic with a chief complaint of painful, itchy eyelids. He reported an exacerbation of conjunctival injection, discharge, and eyelid pain since starting the steroid drops and ointment one-week prior. He also reported three days prior that he had gone to the emergency room because he had blood in his tears. He denied any decrease vision or light sensitivity. POH: Prior to this event - unremarkable PMH: Asthma and Allergic rhinitis FMH: (+) HTN - mother MEDS: Albuterol, baclomethasone dipropionate (Qvar), mometasone (Nasonex), triamcinolone acetonide ung, lotepredenol 0.5% (Lotemax), polymyxin B and trimethoprim (Polytrim), and topical mupirocin Patient was unsure of which mediations to take. ALL: No known drug or environmental allergies SH: Denied tobacco use, reports social alcohol consumption Other salient information: The patient initially had a lesion on the right upper eyelid, in which his PCP started him on a Z-pack (azithromycin) and an unknown ointment. At week 2, there was no improvement in signs or symptoms, so his PCP started amoxicillin and zyrtec. One week later, there was still no improvement to the lids and the eyes had started to become red. The PCP started moxifloxacin (Moxeza) 1gtt TID OU. There was no significant improvement, so the patient was sent to an eye doctor. The eye doctor diagnosed the patient with atopic dermatitis and started triamcinolone ointment BID to both eyelids and Lotemax 1gtt QID OU. The symptoms were exacerbated and he went to the emergency room for bleeding tears. He was prescribed polymyxin B and trimethoprim (Polytrim) and topical mupirocin, but did not use these medication prior to our visit. II. Pertinent Findings Clinical Examination: BCVA: 20/25 OD, 20/25 OS Pupils: PERRL with (-) RAPD EOMs: Smooth, full range of motion CVF: Full to finger counting OD, OS IOP: 19 mmHg OD, 21 mmHg OS SLE . Ocular Adnexa: RUL - Erythema with large erosion and fissure with small honey colored crusts RLL – Erythema with small honey colored crusts LLL – Several macules with honey colored crusts . Conjunctiva: OD>OS 4+ injection, inferior papillae, purulent discharge . Anterior chamber: Deep and quiet . Cornea: Clear. No epithelial defects, no infiltrates, and no superficial neovascularization . Iris: Flat brown, evenly pigmented . Lens: Clear Physical Examination Erythematous papules also seen on lip and right knee. Laboratory Studies Culture Results: . 4+ Staphylococcus Aureus . Oxacillin susceptible (Not MRSA) . Tetracycline susceptible . Trimethoprim/sulfamethoxazole susceptible III. Differential Diagnosis a. Primary: Peri-orbital impetigo with conjunctivitis b. Others: i. Herpes Simplex ii. Herpes Zoster iii. Atopic Dermatitis iv. Contact Dermatitis IV. Diagnosis and Discussion Elaborate on condition Impetigo is a highly contagious, superficial bacterial skin infection (1). In fact, it is the most common bacterial skin infection in children with a peak incidence at two to six years of age (2-4) The incidence is greater in warm, humid environments and in children with poor hygiene (1, 4, 5). The highly contagious lesions, caused by Staphylococcus aureus or Streptococcus pyogenes, can be further separated into non-bullous impetigo (impetigo contagiousa) or bullous impetigo (1). The diagnosis for impetigo is made clinically, thus clinicians should be aware of the clinical appearance. Nonbullous impetigo lesions originate as an erythematous macule or papule that ruptures causing the characteristic honey-colored plaques, whereas in bullous impetigo, bullae with no surrounding erythema rupture to form honey-colored plaques (6). Impetigo tends to localize in areas susceptible to trauma, such as the perinasal, perioral, or periorbital regions (1). Prognosis for impetigo is usually good as lesions heal within one to three weeks without scarring (4, 7). Expound on Unique Features . This case displays how severe impetigo can be in the periorbital region and how to treat and think through impetigo that is non-resolving. The lesions on the knee, lip, and eyelids demonstrate the extensiveness of the impetigo. The extensive lesions help confirm the theory that the anterior nares were colonized with S. Aureus; thus, these areas were becoming colonized after the patient picked his nose and scratched these specific areas. V. Treatment & Management Due to the scarcity of clinical trials, treatment of impetigo with oral antibiotics, topical antibiotics, or disinfectants varies, as there is no widely accepted or standard treatment (8). A recent review showed that topical mupirocin is equally or more effective in treating localized impetigo than oral antibiotics; however, it is still unclear which is more effective in extensive disease (8). Empirical treatment for extensive impetigo was formerly centered around macrolides; however, with the increase in prevalence of methicillin-resistant S. Aureus (MRSA) and the increase of macrolide-resistant bacteria there has been a shift toward using cephalexin, amoxicillin/clavulanic acid, tetracyclines and trimethoprim-sulfamethoxazole as first-line therapy (9, 10). Decolonization of the anterior nares is vital, as nasal carriage can predispose individuals to more extensive disease, as in our patient (7, 11). Once decolonized, mupirocin application to the anterior nares, along with diluted bleach baths, can be used as maintenance therapy to help decrease the staphylococcal bioload and reduce recurrence (12). The patient at our visit was started on polytrim TID, mupirocin to affected regions BID, and trimethoprim-sulfamethoxazole (Bactrim). The patient was referred to have a dermatology consult due to the severe, extensive, and recalcitrant course of the disease. Dermatology confirmed the diagnosis, but started on doxycycline 100mg x 14 days instead of trimethoprim-sulfamethoxazole (Bactrim). Over the course of the next two weeks, significant improvement was noted initially; however, after the patient felt symptomatic improvement, he became non-compliant with medications. Compliance was stressed. Over the following two weeks the patient was decolonized and the patient was instructed to start diluted bleach baths two to three times a week and apply mupirocin to the anterior nares for five consecutive days as maintenance. Both of these were to be repeated monthly to avoid recurrence. Currently, the impetigo is almost resolved and now a there is an underlying dermatitis on the right upper eyelid. Pimecrolimus (Elidel) was prescribed BID. Follow-up appointments have been scheduled with the dermatologist to determine effectiveness of treatment. VI. Conclusion Clinical Pearls Exacerbation with steroids, think infectious. If diseases are extensive, severe, or non-responsive, culture! Don’t just look at the eyes. In this case paying attention to the new lesions on the lip and the knee can help accurately diagnose a patient with a complicated history. Don’t be a superhero. Proper co-management with other professions is vital in patient care. VII. Bibliography 1. Brown J, Shriner DL, Schwartz RA, Janniger CK. Impetigo: an update. Int J Dermatol. 2003;42(4):251-5. 2. Yang LP, Keam SJ. Spotlight on retapamulin in impetigo and other uncomplicated superficial skin infections. Am J Clin Dermatol. 2008;9(6):411-3. 3. Rortveit S, Rortveit G. Impetigo in epidemic and nonepidemic phases: an incidence study over 4(1/2) years in a general population. Br J Dermatol. 2007;157(1):100-5. 4. Cole C, Gazewood J. Diagnosis and treatment of impetigo. Am Fam Physician. 2007;75(6):859-64. 5. Hirschmann JV. Impetigo: etiology and therapy. Curr Clin Top Infect Dis. 2002;22:42-51. 6. Dagan R. Impetigo in childhood: changing epidemiology and new treatments. Pediatr Ann. 1993;22(4):235-40. 7. Sladden MJ, Johnston GA. Common skin infections in children. BMJ. 2004;329(7457):95-9. 8. Koning S, van der Sande R, Verhagen AP, van Suijlekom-Smit LW, Morris AD, Butler CC, et al. Interventions for impetigo. Cochrane Database Syst Rev. 2012;1:CD003261. 9. Bangert S, Levy M, Hebert AA. Bacterial resistance and impetigo treatment trends: a review. Pediatr Dermatol. 2012;29(3):243-8. 10. Silverberg N, Block S. Uncomplicated skin and skin structure infections in children: diagnosis and current treatment options in the United States. Clin Pediatr (Phila). 2008;47(3):211-9. 11. Durupt F, Mayor L, Bes M, Reverdy ME, Vandenesch F, Thomas L, et al. Prevalence of Staphylococcus aureus toxins and nasal carriage in furuncles and impetigo. Br J Dermatol. 2007;157(6):1161-7. 12. Huang YH, Chen YP, Liang CC, Chang YL, Hsieh CC. Impetigo herpetiformis with gestational hypertension: a case report and literature review. Dermatology. 2011;222(3):221-4. .
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