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H.P.I.-M.Z 9/9-11a.m.

H.P.I.-M.Z 9/9-11a.m. 40y/o male with swelling,redness,and drainage from the left eye for last few days. E.O.M.’s intact.”No suspicion of deep infection at this time”. Treatment Keflex 500mg Q 6hr P.O. and check with Ophthalmology in the a.m. (1gram of Rocephin i.m.). M.Z. 9/10 2am.

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H.P.I.-M.Z 9/9-11a.m.

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  1. H.P.I.-M.Z 9/9-11a.m. • 40y/o male with swelling,redness,and drainage from the left eye for last few days. • E.O.M.’s intact.”No suspicion of deep infection at this time”. • Treatment Keflex 500mg Q 6hr P.O. and check with Ophthalmology in the a.m. • (1gram of Rocephin i.m.)

  2. M.Z. 9/10 2am • 2a.m. 9/10 M..Z. referred from Sauk City E.R. with severe headache,periorbital pain, proptosis,lateral globe displacement,and restricted adduction. (-) A.P.D. V.A. 20/80 • Cat scan:Ethmoid/Maxillary sinusitis and 25 m.m.x11m.m. subperiosteal abscess • P.M.H. 1996 Mandibular fracture & Ethmoid (medial wall) fracture(Supramid implant). Dental work 4 days ago

  3. Subperiosteal Abcess

  4. Hospital Course • Dx.Orbital Cellulitis with Subperiostal abscess. • Team approach P.C.P.,Infectious Disease, and Oculoplastic surgeon • Tx. Ceftriaxone 2gm q 12hr.iv, Clindamycin 900 mg q 8 hr,Vancomycin 1 gm,q12 hr. started immediately • 9/11 (L) orbitotomy with removal of implant and abscess drainage. Culture alpha Strep &coag.neg Staph. • Discharged 9/15 on oral antibiotics, symptoms resolved vision normal.

  5. MRSA • Community acquired • Increased potential for tissue invasion • Found in young athletes and inmates • Progresses despite appropriate treatment

  6. Case Review Day 1: 44 yr old male squeezed a pustule in his nose Day 3: fever and chills developed, treated with TMP/SMX DS and Rifampin Day 4: Admitted for eyelid swelling, WBC 24,000.Rx- Vancomycin + Ceftriaxone + Metronidazole Day 5: Massive proptosis, ophthalmoplegia, bilateral vision loss

  7. Findings • Pupils unreactive, central retinal arteries and veins occluded • Congestion of optic discs • Orbital and brain MRI –bilateral orbital cellulitis, pansinusitis, cavernous sinus enlargement • MR venogram confirmed cavernous sinus thrombosis

  8. Hospital course • Paranasal sinuses drained endoscopically • Day 13: iv heparin and methylprednisolone • In retrospect, may have benefited from orbital decompression sooner

  9. Preseptal cellulitis RX Dicloxacillin Augmentin Macrolides Quinolones 3rd gen. Cephalosporin

  10. Orbital Cellulitis • Ceftriaxone & Metronidazole Vancomycin • Ampicillin/Sulbactam • Ticarcillin/Clavulanic acid & Vancomycin • Imipenen/Meropenem & Vancomycin • Fluoroquinolone & Clindamycin • Aztreonam • Amphotericin

  11. Team Work EYE ENT ID NEUROSURGERY

  12. HEADS UP • Team Approach • History very important in determining the most likely organism. Culture may be • difficult. • Frequent re-evaluations are necessary. • Imaging studies are very helpful in diagnosis and monitoring treatment. • Serious problem can result in death.

  13. Infection Orbital cellulitis Cavernous sinus thrombosis Neoplastic Metastatic Ca Lymphoma Rhabdomyosarcoma Retinoblastoma Leukemia Letterer-Siwe disease Endocrine Orbital Inflammation Pseudotumor Orbital myositis Wegener’ granulo- matosis Differential Dx. Proptosis

  14. ANATOMY

  15. Haemophilus Influenzae

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