Periorbital cellulitis is common in children. It is often caused by infections of the neighboring sinuses. According to Chandler's classification,' periorbital or preseptal cellulitis is frequent and usually has a benign course if adequately treated. Its prognosis is clearly different from that of retroseptal cellulitis, which may be followed by complications. Several recent articles2'3 have dealt with the therapeutic modalities for treating these conditions, depending on the clinical severity and the microbiological spectrum in children.
However, the occurrence of cellulitis in the orbital region in the neonate is rare.4 Furthermore, the anatomic structures and microbial flora of neonates are not identical to those of older children, who are more commonly affected. We report a case of orbital abscess identified in a 3-week-old neonate presenting with an acute proptosis and fever.
A full-term female neonate had a normal perinatal history and no particular infectious risk. On the 17th day of life, she had fever; this continued the following day and was associated with a clear nasal discharge, a watery left eye, and cough. The attending physician initiated treatment with amoxicillin. Three days later, palpebrai swelling, periocular redness, and pronounced proptosis of the left eye were observed (Fig. 1). Initial investigations demonstrated Ieukocytosis (16,700/mm3), an elevated Creactive protein level (88 mg/L), and normal cerebrospinal fluid. A computed tomography (CT) scan of the brain revealed a retrobulbar mass. The neonate was referred to our center for treatment. On admission, she appeared uncomfortable with pyrexia of 38.20C.
Figure 1. The neonate has palpebrai swelling, proptosis, and periocular redness of the left eye.
An examination of the left eye showed a significant proptosis and a purple hue on the eyelid with increased local temperature. The pupils reacted normally, and the ocular motility seemed maintained and normal for age. The optic discs had a normal coloration and were demarcated. Intravenous antibiotics (vancomycin and gentamicin) were started and dexamethasone was administered. A second CT scan confirmed the presence of an intraorbital lesion in contact with the superior rectus muscle and revealed swelling of the left lacrimal gland and fullness of the inner canthus. Magnetic resonance imaging (MRI) showed an intraorbital, intraconical, and upper- extern al abscess located at the level of the superior rectus muscle of the left eye, pushing the globe forward and downward (Fig. 2).
The patient underwent surgical exploration with orbital decompression and drainage of a purulent abscess located under the periorbit in the orbital conus by craniotomy. A culture of the pus was positive for Staphylococcus aureus sensitive to methicillin. The treatment was changed to intravenous floxacillin for a total of 14 days. The postoperative course was uneventful.
Figure 2. Magnetic resonance imaging of the central nervous system showing an intraorbital, i n traconi cal, upper-external abscess of the left eye (arrows).
An ophthalmo logic examin ario n soon after showed a significant reduction of the proptosis and normal ocular mobility with fixation of light. Funduscopy revealed no ab normal i ti es. One month later, die neonate had an excellent recovery.
The acute onset of proptosis in a neonate is a rarely described symptom that may be indicative of different pathologic conditions, which may be of infectious, tumoral, or vascular origin.5 The fever, the elevation of inflammatory parameters in the blood, and die ne uro radiologie features in our case were consistent with an infectious process. Because of the compression of intraorbital structures, surgery was indicated and confirmed the presence of an intraconic abscess.
Our hypothesis is that its source might be the adjacent lacrimal gland, as suggested by the upperexternal location of the abscess and the swelling of the gland observed on both the CT scan and MRI. This has never been described in this age group. The postoperative examination and the subsequent clinical observations did not reveal obstruction of the lacrimal system.
Israele and Nelson6 reviewed the records of 178 children with cellulítis of the orbital region and identified only 12 cases of retroseptal cellulitis (7%), confirming their frequency in other studies of between 4% and 28%. They analyzed series or cases reported since 1890 in the literature and were able to identify 1 ,438 other cases of celiulitis. The average age of children with orbital cellulitis was significantly older than that of children with preseptal celluiitis (average, 7.4 years vs 33 months}. Only 1 1 neonates with orbital cellulitis were described in whom the suspected etiology was hematogenous dissemination from other foci, such as the lungs or skin,7 or secondary infection of conjunctiva! malformation.8 There were no cases of si nusitis, in contrast to the dearly demonstrated association between retroseptal cellulitis and sinusitis in older children. In 90% of these cases, Staphylococcus was the pathogen responsible.
Molane et al.4 examined the characteristics of periorbital cellulitis in a series of 30 children younger than 1 year, including 7 neonates, but found no cases of retroseptal cellulitis. In the group of neonates, a ruptured dacryocele or dacryocystitis were important predisposing factors. Implication of S. aureus was also found frequently in this group. An orbital abscess as a complication of dacryocystitis has been described in a 17-day-old infant.9 A periorbital abscess as a complication of ethmoiditis in a 2-week-old infant has also been reported.10 In these two cases, the abscesses were located within the medial compartment of the orbit and therefore adjacent to the primary sites of infection.
In our case, none of these risk factors were found and the abscess was located in an external position within the orbit. The history of clear nasal discharge followed by a watery eye suggests conjunctivitis, but the swelling of the lacrimal gland could be indicative of a secondary dacry o adenitis. Because a part of the lacrimal gland is intraorbital, this can theoretically be a source of retroseptal infection, but it has never been described.
An orbital abscess in the neonate is rare and differs from that of older children by a less common association with sinusitis and possibly more frequent involvement of the lacrimal duct or conjunctivae. Ne uro radio logic imaging is mandatory to confirm the diagnosis, visualize the adjacent structures, and localize ihe lesion precisely. A surgical intervention is mandatory in the case of compression of the ocular structures. Given the preponderance of 5. aureus as the pathogenic agent in this age group, antibiotic therapy should include an antistaphylococcal drug.
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