561356
research-article2014
CPJXXX10.1177/0009922814561356Clinical PediatricsSayani and Smith
Article
Clinical Recognition and Management of an Atypical Dacryoadenitis
Clinical Pediatrics 1–5 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814561356 cpj.sagepub.com
Amar Sayani, OD, FAAO1, and Daniel E. Smith, OD, FAAO2
Abstract Dacryoadenitis, a condition defined as inflammation of the lacrimal gland, has many etiologies; rarely is it associated with a lacrimal gland abscess. In this article, a 7-year-old African American boy was diagnosed with a lacrimal gland abscess secondary to oxacillin-resistant Staphylococcus aureus (ORSA). The incidence of conditions arising from ORSA, a term used interchangeably with methicillin-resistant S aureus (MRSA), is reportedly on the rise in our population over the past decade. Recognition of atypical pathogens, initiation of timely appropriate-spectrum pharmaceuticals, and conservative follow-up are imperative in treating and preventing potentially vision-threatening sequelae of dacryoadenitis. Keywords dacryoadenitis, orbital abscess, oxacillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, subperiosteal abscess, orbital cellulitis
Introduction Dacryoadenitis is defined as inflammation of the lacrimal gland resulting in edema, erythema, and tenderness in the superior temporal aspect of the orbit. Typically, it is a result of either local bacterial or viral infections such as Staphylococcus, herpes zoster, or gonococcus. It can also be secondary to systemic inflammatory conditions such as sarcoidosis, thyroid eye disease, syphilis, or tuberculosis. Dacryoadenitis of infectious origin is acute and unilateral, whereas those secondary to inflammatory conditions are more chronic and bilateral in nature.1 This case is remarkable in that the underlying etiology is oxacillin-resistant Staphylococcus aureus, resulting in an encapsulated abscess of the lacrimal gland of a 7-year-old patient; it also demonstrates clinical features that may be useful in predicting an atypical offending agent prior to culturing or waiting for initial therapies to fail.
Case Description A 7-year-old boy presented to the clinic in December 2012 with complaints of an injected left eye and mildly edematous left superior eyelid. On initial onset, he reported only mild pain, and his guardian offered no significant medical or ocular history other than him being seen by a primary care physician 5 days earlier for the same swollen eyelid. At that time, he was prescribed gentamycin ophthalmic solution 3 times daily in the left eye.
Past ocular history included an eye exam 2 years prior. There were no complications during the full-term pregnancy, and he was delivered via cesarean section. Following birth, he was placed in the intensive care unit for 3 weeks because of meconium aspiration. His past ocular history was remarkable for recurrent hordeola of the left eye. Medical history was positive for chronic nasal congestion and sickle cell trait, and family history was consistent with sickle cell disease (maternal). He did not have any known drug allergies and was only using gentamycin topical ophthalmic solution at the time of presentation. Uncorrected visual acuities were recorded as 20/20 OD, OS, and OU at 6M. Pupils were equally round and reactive to light, with no afferent pupillary defect OU. Confrontation fields were full to finger count OU, and ocular motilities were smooth and full without restriction OU. Convergence was intact, and cover test displayed orthophoria at 6 m and 40 cm. Anterior segment evaluation revealed moderate edema of the left upper lid and trace chemosis of the left temporal bulbar conjunctiva. The anterior segment was otherwise unremarkable 1
Rochester Ophthalmological Group, Rochester, NY, USA Children’s Hospital Colorado, Aurora, CO, USA
2
Corresponding Author: Daniel E. Smith, Children’s Hospital Colorado, 13123 E 16th Ave B430, Aurora, CO 80045, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 22, 2015
2
Clinical Pediatrics
Figure 1. Ocular adnexa photograph of swelling concentrated on superior temporal eyelid OS after initial treatment, which included oral antibiotics.
OU. The remainder of the slit lamp examination was unremarkable, both corneas were clear OU, irides were brown OU, anterior chamber was clear without cells or flare, and angles were 4 × 4 by Von Herrick OU. Lenses were clear OU. He was diagnosed with a preseptal cellulitis secondary to chronic hordeola and treated with a 10-day, 20-mg/kg/d course of oral Augmentin, as well as, topical Zylet ophthalmic solution 3 times a day OS. Despite the combined antibiotic and steroid therapy, he returned 4 days later with significant worsening of clinical signs and symptoms. Uncorrected visual acuities were now recorded as 20/20 OD and 20/40 OS. There was no improvement in acuity in the left eye through pinhole testing. Pupils were equally round and reactive to light, and no afferent pupillary defect was noted OU. Confrontation fields were full to finger count OU. Extraocular muscles were full and unrestricted in all gazes with the right eye, though the left eye now demonstrated an abduction deficit, with pain on movement. Intraocular pressure was soft to palpation (normal) OU. Anterior segment evaluation revealed marked lid swelling, concentrated on the superior temporal aspect of the left eye (Figure 1). In addition, an increase in temporal bulbar conjunctival chemosis and a clear discharge were noted (Figure 2). The patient’s mother reported that discharge had begun 1 or 2 days previously. The remainder of the slit lamp and 90-D fundus examination was unremarkable. Preauricular nodes were nonpalpable and nontender. The patient was not febrile, and through gross assessment there was no proptosis evident. The resulting differential diagnoses considered in this particular case now included preseptal cellulitis, orbital cellulitis, lacrimal gland tumor, lymphangioma, allergic conjunctivitis/dermatitis, and dacryoadenitis secondary to either atypical infectious or systemic inflammatory mediators.
Figure 2. Anterior segment photograph of temporal conjunctival chemosis and clear discharge OS after initial treatment with an ophthalmic steroid solution.
Given the increased edema, chemosis, and unresponsiveness to oral antibiotics, blood work and neuroimaging was ordered. The patient was referred to a local children’s hospital for a complete blood count with differential, angiotensin-converting enzyme (ACE), chest X ray, fluorescent treponemal antibody absorption (FTA-ABS), Gram stain/cultures, and computed tomography scan of the orbit. Serum testing indicated only slightly elevated neutrophils confirming the presence of inflammation and/or infection. The result of the imaging identified a welldemarcated cyst in the superior temporal aspect of the globe involving the lacrimal gland. Figure 3 illustrates the abscess, and closer examination of the figure shows the abscess impinging on the lateral rectus in the left eye, accounting for the abduction deficit noted during clinical examination. The size of the abscess was measured as 13 mm × 8 mm × 11 mm. This is a large abscess because the lacrimal gland has been described often to be the size of a small almond. The typical dimensions for the normal lacrimal gland are approximately 15 mm × 5 mm × 10 mm.2 The size and lateral extent of the abscess and its inflammatory mediators are evident in Figure 4. Surgical excision and drainage was performed the same day. A Penrose drain was left in place so that drainage of the abscess could occur over the following few days. A Penrose drain is a device that drains the abscess slowly through the skin so that the integrity of the lacrimal apparatus is not compromised.3 Culturing of the lesion confirmed oxacillin-resistant S aureus. The patient was admitted and placed on IV antibiotics, specifically, clindamycin and ceftriaxone, and discharged 3 days later on resolution of the abscess.
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 22, 2015
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Sayani and Smith
Figure 3. Axial computed tomography scan demonstrating left lacrimal gland abscess (arrow).
Figure 4. Coronal computed tomography scan demonstrating left lacrimal gland abscess (arrow).
Discussion With a reported incidence of 1:10 000, dacryoadenitis is still considered an uncommon anomaly in ophthalmic settings.4 Described as inflammation of the lacrimal gland resulting from obstruction of the continuity between the conjunctiva and the lacrimal ducts, potential etiologies include infection, trauma, or neoplasms. Systemic inflammatory conditions such as sarcoidosis
and thyroid eye disease have also been implicated, though diagnostic workup for these conditions is usually reserved for those patients presenting with bilateral involvement.5 Typical clinical presentation, as in the case described, includes erythema and edema of the lateral portion of the upper lid, often creating the diagnostic S-shaped distortion of the upper-lid margin, with associated tenderness. This S-shaped feature is anatomically explained by the lacrimal drainage apparatus being preseptal, whereas the majority of the secretory unit lacrimal gland is postseptal. The serious prognosis of the condition stems from the potential migration of disease into the orbit via thrombophlebitis, direct extension from bony erosion, or bony dehiscence, which can result in orbital cellulitis and ultimately lead to detrimental effects such as optic neuropathy, acuity loss, and motility deficits if not treated promptly.6 The interesting aspect of this case was that the condition demonstrated a rapid progression from an acute dacryoadenitis to low-grade orbital cellulitis despite the absence of paranasal sinus disease, antecedent upper-respiratory infection, or trauma. It has been well documented that sinus disease accounts for most orbital cellulitis cases.7 Through the aforementioned routes of migration, it is easy to understand (anatomically speaking) the vulnerability of the lacrimal gland when surrounding orbital tissue becomes pathologically compromised. Because the most common pathogens of sinus disease are Gram-positive staphylococcal or streptococcal microbes, appropriate initial medical care was applied when the patient was prescribed oral Augmentin. Augmentin consists of amoxicillin, a moderate spectrum antibiotic that works by inhibiting synthesis of bacterial cell walls, and clavulanic acid, also a β-lactam antibiotic that when combined with amoxicillin provides slightly better coverage for staphylococci bacteria. Therefore, given the lack of improvement and progression of disease into the orbit, an atypical pathogen was suspected. When considering diagnostic and therapeutic approaches for this, and all preseptal/orbital abscess cases, 3 questions emerge, which are discussed below.
Given the Vulnerability of the Histology of the Orbit, Should Methicillin-Resistant Staphylococcus aureus (MRSA) Drugs Be the First Line of Defense for Treatment of Abscesses Regardless of Location or Etiology? A confounding variable in the identification and treatment of orbital infection is recognizing and managing a multidrug-resistant offending agent. Traditionally, MRSA is suspected only after administration of common, broadspectrum antibiotics with more palatable safety profiles
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 22, 2015
4
Clinical Pediatrics
provide no resolution. Reservation to prescribing MRSA drugs is justified because of the low-risk, yet damaging, side effects associated with them—for example, StevensJohnson syndrome or Clostridium difficile infection. Given the high correlation between upper-respiratory and/or sinus disease and orbital cellulitis and other ocular infection, Mathias et al8 have previously suggested that the absence of these associations could be used as a predictive factor suggesting a methicillin-resistant pathogen prior to the use of any pharmaceutical. It is the opinion of the authors that unilateral presentation is additional support for this suspicion. If the prevalence of MRSA continues, drugs with ORSA coverage, such as vancomycin, clindamycin, or sulfamethoxazole, may become the appropriate initial medical therapy.
Should Cultures Be Taken on Every Abscess Patient? Culturing is not common practice in typical eye care settings.9 The majority of ocular infectious events is superficial and uncomplicated. Therefore, culturing has become a procedure reserved for conditions that do not have a timely response to traditional therapy, have immediate visual debilitating implications, or result in the formation of a subperiosteal abscess that requires drainage because of the lack of antimicrobial penetrance. It is reasonable to justify the lack of culturing for preseptal cellulitis, given the questionable yield a clinician would receive from obtaining only a conjunctival swab. However, if an abscess requires drainage and intravenous antibiotics, culturing is expected. When a culture is obtained, it is imperative that the clinician understand that there are many endogenous microorganisms in and around the orbit. A negative culture from the lab does not necessarily indicate the absence of microbial growth on an agar dish but rather identifies expected microbes in their usual concentration. A positive culture identifies either an atypical agent in any concentration or unusual concentration of normal flora. Therefore, it is the responsibility of the clinician to know the resident flora of the eye and understand how each lab reports its findings before deciding on a monomicrobial or polymicrobial cause, if they choose to culture.9
Should Radiological Imaging Be Reserved Only for Orbital and Not Preseptal Cellulitis Patients? Radiological imaging of abscess formation is critical in determining the extent of disease migration. Infection of the globe would imply containment of the microorganism
within the confines of the Tenon’s capsule, whereas an orbital infection includes invasion into the orbital bone, soft tissue, muscles, and/or nerve. Being more specific, preseptal cellulitis is inflammation/infection anterior to the septum extending from the periosteum of the orbital rim to the tarsal plate of the eyelids. A preseptal location of infection is much more common, less invasive, and more manageable than that of orbital cellulitis, making the indication for imaging less likely. However, imaging is required when there is ocular displacement resulting from potential abscess formation. Radiological imaging of this patient did not provide data on the origin of infection, though it did confirm the presence of the lacrimal abscess. The frontal sinus is assumed to be the source of infection, with migration coming through the dehiscence found in the middle to outer third of the sinus floor. The significance of immediate treatment comes from the understanding of rapid contiguous spread of infection through the ophthalmic venous system—hence the use of Penrose tube drainage and MRSA antimicrobial agents. We could speculate that the recurrent nature of his hordeola was the culprit, though the time frame of last recurrence and their previous self-limiting nature complicated this issue.
Conclusion MRSA infections are commonly known to occur in hospitals or other health care environments. Among the pediatric population, MRSA infections are rapidly on the rise. One cross-sectional study reports that MRSA increased from 4.1% in 1998-1999 to an alarming 16.7% in 2005-2006.10 This is a dramatic increase in the incidence of MRSA infections over a period of less than a decade. The first reported, documented case of dacryoadenitis associated with MRSA was in 2008, and MRSA infections in pediatric populations have been increasing dramatically, as evident in the literature since that time.8,11 This case illustrates the susceptibility of the pediatric and adolescent population to MRSA infections within the orbit as the primary infection site. For this case, initial treatment for the dacryoadenitis was the use of oral Augmentin, a β-lactamase inhibiting drug. As demonstrated, this broad-spectrum antibiotic proved to be ineffective, resulting in increased edema of the eyelid and chemosis of the temporal conjunctiva, thus necessitating additional cellulitis workup. As previously mentioned, this case is unique in that it presents clinical characteristics that serve somewhat as predictive indicators, implicating a drug-resistant agent prior to culturing or the selection of Augmentin for initial treatment. First, the condition was unilateral, diminishing the probability of
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 22, 2015
5
Sayani and Smith a systemic inflammatory cause. Second, the progression of the clinical signs was very aggressive. And third, sinus disease or antecedent upper-respiratory infections usually associated with orbital cellulitis cases were absent. As bacteria continue to evolve, they develop mechanisms to counter advances in our modern antibiotic therapies. Collectively, these evolving bacteria are known as MRSA.12 On diagnosis of this lacrimal gland abscess, same-day surgical excision and drainage of the abscess was critical because over time, an abscess poses the risk of emptying into the orbit and, ultimately, into the brain, which would be potentially life threatening. The intravenous antibiotic treatment with clindamycin and ceftriaxone in the case of a methicillin- or oxacillin-resistant S aureus infection is supported in the literature and is the treatment of choice for MRSA/ORSA infections.13,14 In medical offices, early suspicion for or detection of atypical pathogens, use of appropriate antibiotics, and conservative consultative care is critical in the care of these patients. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Gagan SJ, Hampton R, eds. Dacryoadenitis treatment and management. http://emedicine.medscape.com/ article/121-0342-treatment. Accessed January 16, 2013. 2. Lorber M. Gross characteristics of normal lacrimal glands. Ocul Surf. 2007;5:13-22.
3. Flax LH, Gould EA. A new surgical drain used in 54 surgical cases without producing any undesirable effects. JAMA. 1961;177:150-151. 4. Srivistava VK. Acute suppurative dacryoadenitis. Med J Armed Forces India. 2000;56:151-152. 5. Berlanger C, Zhang KS, Reddy AK, Yen MT, Yen KG. Inflammatory disorders of the orbit in childhood: a case series. Am J Ophthalmol. 2010;150:460-463. 6. Pond F, Berkowitz RG. Superolateral subperiosteal orbital abscess complicating sinusitis in a child. Int J Pediatr Otorhinolaryngol. 1999;48:255-258. 7. Schramm VL Jr, Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope. 1982;92(7, pt 1):732-738. 8. Mathias MT, Horsley MB, Mawn LA, et al. Atypical presentations of orbital cellulitis caused by methicillin-resistant Staphylococcus aureus. Ophthalmology. 2012;119:1238-1243. 9. Blondeau JM. The positive benefits of a negative culture. Top Ocul Anti Infect. 2013;(41):1-4. 10. Freidlin J, Acharya N, Lietman TM, Cevallos V, Whitcher JP, Margolis TP. Spectrum of eye disease caused by methicillin-resistant Staphylococcus aureus. Am J Ophthalmol. 2007;144:313-315. 11. Kubal A, Garibaldi DC. Dacryoadenitis caused by methicillin-resistant Staphylococcus aureus. Ophthal Plast Reconstr Surg. 2008;24:50-51. 12. Jackson-Michel S. Antibiotics used to treat Staphylococcus aureus. Live Strong. http://www.livestrong.com/article/206040-antibiotics-used-to-treat-staphylococcus-aureus/13. 13. Carrillo-Marquez MA, Hulten KG, Hammerman W, Lamberth L, Mason EO, Kaplan SL. Staphylococcus aureus pneumonia in children in the era of communityacquired methicillin-resistance at Texas Children’s Hospital. Pediatr Infect Dis J. 2011;30:545-550. 14. Abdel-Haq NM, Quezada M, Asmar BI. Retropharyngeal abscess in children: the rising incidence of methicillinresistant Staphylococcus aureus. Pediatr Infect Dis J. 2012;31:696-699.
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 22, 2015
research-article2014
CPJXXX10.1177/0009922814561356Clinical PediatricsSayani and Smith
Article
Clinical Recognition and Management of an Atypical Dacryoadenitis
Clinical Pediatrics 1–5 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814561356 cpj.sagepub.com
Amar Sayani, OD, FAAO1, and Daniel E. Smith, OD, FAAO2
Abstract Dacryoadenitis, a condition defined as inflammation of the lacrimal gland, has many etiologies; rarely is it associated with a lacrimal gland abscess. In this article, a 7-year-old African American boy was diagnosed with a lacrimal gland abscess secondary to oxacillin-resistant Staphylococcus aureus (ORSA). The incidence of conditions arising from ORSA, a term used interchangeably with methicillin-resistant S aureus (MRSA), is reportedly on the rise in our population over the past decade. Recognition of atypical pathogens, initiation of timely appropriate-spectrum pharmaceuticals, and conservative follow-up are imperative in treating and preventing potentially vision-threatening sequelae of dacryoadenitis. Keywords dacryoadenitis, orbital abscess, oxacillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, subperiosteal abscess, orbital cellulitis
Introduction Dacryoadenitis is defined as inflammation of the lacrimal gland resulting in edema, erythema, and tenderness in the superior temporal aspect of the orbit. Typically, it is a result of either local bacterial or viral infections such as Staphylococcus, herpes zoster, or gonococcus. It can also be secondary to systemic inflammatory conditions such as sarcoidosis, thyroid eye disease, syphilis, or tuberculosis. Dacryoadenitis of infectious origin is acute and unilateral, whereas those secondary to inflammatory conditions are more chronic and bilateral in nature.1 This case is remarkable in that the underlying etiology is oxacillin-resistant Staphylococcus aureus, resulting in an encapsulated abscess of the lacrimal gland of a 7-year-old patient; it also demonstrates clinical features that may be useful in predicting an atypical offending agent prior to culturing or waiting for initial therapies to fail.
Case Description A 7-year-old boy presented to the clinic in December 2012 with complaints of an injected left eye and mildly edematous left superior eyelid. On initial onset, he reported only mild pain, and his guardian offered no significant medical or ocular history other than him being seen by a primary care physician 5 days earlier for the same swollen eyelid. At that time, he was prescribed gentamycin ophthalmic solution 3 times daily in the left eye.
Past ocular history included an eye exam 2 years prior. There were no complications during the full-term pregnancy, and he was delivered via cesarean section. Following birth, he was placed in the intensive care unit for 3 weeks because of meconium aspiration. His past ocular history was remarkable for recurrent hordeola of the left eye. Medical history was positive for chronic nasal congestion and sickle cell trait, and family history was consistent with sickle cell disease (maternal). He did not have any known drug allergies and was only using gentamycin topical ophthalmic solution at the time of presentation. Uncorrected visual acuities were recorded as 20/20 OD, OS, and OU at 6M. Pupils were equally round and reactive to light, with no afferent pupillary defect OU. Confrontation fields were full to finger count OU, and ocular motilities were smooth and full without restriction OU. Convergence was intact, and cover test displayed orthophoria at 6 m and 40 cm. Anterior segment evaluation revealed moderate edema of the left upper lid and trace chemosis of the left temporal bulbar conjunctiva. The anterior segment was otherwise unremarkable 1
Rochester Ophthalmological Group, Rochester, NY, USA Children’s Hospital Colorado, Aurora, CO, USA
2
Corresponding Author: Daniel E. Smith, Children’s Hospital Colorado, 13123 E 16th Ave B430, Aurora, CO 80045, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 22, 2015
2
Clinical Pediatrics
Figure 1. Ocular adnexa photograph of swelling concentrated on superior temporal eyelid OS after initial treatment, which included oral antibiotics.
OU. The remainder of the slit lamp examination was unremarkable, both corneas were clear OU, irides were brown OU, anterior chamber was clear without cells or flare, and angles were 4 × 4 by Von Herrick OU. Lenses were clear OU. He was diagnosed with a preseptal cellulitis secondary to chronic hordeola and treated with a 10-day, 20-mg/kg/d course of oral Augmentin, as well as, topical Zylet ophthalmic solution 3 times a day OS. Despite the combined antibiotic and steroid therapy, he returned 4 days later with significant worsening of clinical signs and symptoms. Uncorrected visual acuities were now recorded as 20/20 OD and 20/40 OS. There was no improvement in acuity in the left eye through pinhole testing. Pupils were equally round and reactive to light, and no afferent pupillary defect was noted OU. Confrontation fields were full to finger count OU. Extraocular muscles were full and unrestricted in all gazes with the right eye, though the left eye now demonstrated an abduction deficit, with pain on movement. Intraocular pressure was soft to palpation (normal) OU. Anterior segment evaluation revealed marked lid swelling, concentrated on the superior temporal aspect of the left eye (Figure 1). In addition, an increase in temporal bulbar conjunctival chemosis and a clear discharge were noted (Figure 2). The patient’s mother reported that discharge had begun 1 or 2 days previously. The remainder of the slit lamp and 90-D fundus examination was unremarkable. Preauricular nodes were nonpalpable and nontender. The patient was not febrile, and through gross assessment there was no proptosis evident. The resulting differential diagnoses considered in this particular case now included preseptal cellulitis, orbital cellulitis, lacrimal gland tumor, lymphangioma, allergic conjunctivitis/dermatitis, and dacryoadenitis secondary to either atypical infectious or systemic inflammatory mediators.
Figure 2. Anterior segment photograph of temporal conjunctival chemosis and clear discharge OS after initial treatment with an ophthalmic steroid solution.
Given the increased edema, chemosis, and unresponsiveness to oral antibiotics, blood work and neuroimaging was ordered. The patient was referred to a local children’s hospital for a complete blood count with differential, angiotensin-converting enzyme (ACE), chest X ray, fluorescent treponemal antibody absorption (FTA-ABS), Gram stain/cultures, and computed tomography scan of the orbit. Serum testing indicated only slightly elevated neutrophils confirming the presence of inflammation and/or infection. The result of the imaging identified a welldemarcated cyst in the superior temporal aspect of the globe involving the lacrimal gland. Figure 3 illustrates the abscess, and closer examination of the figure shows the abscess impinging on the lateral rectus in the left eye, accounting for the abduction deficit noted during clinical examination. The size of the abscess was measured as 13 mm × 8 mm × 11 mm. This is a large abscess because the lacrimal gland has been described often to be the size of a small almond. The typical dimensions for the normal lacrimal gland are approximately 15 mm × 5 mm × 10 mm.2 The size and lateral extent of the abscess and its inflammatory mediators are evident in Figure 4. Surgical excision and drainage was performed the same day. A Penrose drain was left in place so that drainage of the abscess could occur over the following few days. A Penrose drain is a device that drains the abscess slowly through the skin so that the integrity of the lacrimal apparatus is not compromised.3 Culturing of the lesion confirmed oxacillin-resistant S aureus. The patient was admitted and placed on IV antibiotics, specifically, clindamycin and ceftriaxone, and discharged 3 days later on resolution of the abscess.
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 22, 2015
3
Sayani and Smith
Figure 3. Axial computed tomography scan demonstrating left lacrimal gland abscess (arrow).
Figure 4. Coronal computed tomography scan demonstrating left lacrimal gland abscess (arrow).
Discussion With a reported incidence of 1:10 000, dacryoadenitis is still considered an uncommon anomaly in ophthalmic settings.4 Described as inflammation of the lacrimal gland resulting from obstruction of the continuity between the conjunctiva and the lacrimal ducts, potential etiologies include infection, trauma, or neoplasms. Systemic inflammatory conditions such as sarcoidosis
and thyroid eye disease have also been implicated, though diagnostic workup for these conditions is usually reserved for those patients presenting with bilateral involvement.5 Typical clinical presentation, as in the case described, includes erythema and edema of the lateral portion of the upper lid, often creating the diagnostic S-shaped distortion of the upper-lid margin, with associated tenderness. This S-shaped feature is anatomically explained by the lacrimal drainage apparatus being preseptal, whereas the majority of the secretory unit lacrimal gland is postseptal. The serious prognosis of the condition stems from the potential migration of disease into the orbit via thrombophlebitis, direct extension from bony erosion, or bony dehiscence, which can result in orbital cellulitis and ultimately lead to detrimental effects such as optic neuropathy, acuity loss, and motility deficits if not treated promptly.6 The interesting aspect of this case was that the condition demonstrated a rapid progression from an acute dacryoadenitis to low-grade orbital cellulitis despite the absence of paranasal sinus disease, antecedent upper-respiratory infection, or trauma. It has been well documented that sinus disease accounts for most orbital cellulitis cases.7 Through the aforementioned routes of migration, it is easy to understand (anatomically speaking) the vulnerability of the lacrimal gland when surrounding orbital tissue becomes pathologically compromised. Because the most common pathogens of sinus disease are Gram-positive staphylococcal or streptococcal microbes, appropriate initial medical care was applied when the patient was prescribed oral Augmentin. Augmentin consists of amoxicillin, a moderate spectrum antibiotic that works by inhibiting synthesis of bacterial cell walls, and clavulanic acid, also a β-lactam antibiotic that when combined with amoxicillin provides slightly better coverage for staphylococci bacteria. Therefore, given the lack of improvement and progression of disease into the orbit, an atypical pathogen was suspected. When considering diagnostic and therapeutic approaches for this, and all preseptal/orbital abscess cases, 3 questions emerge, which are discussed below.
Given the Vulnerability of the Histology of the Orbit, Should Methicillin-Resistant Staphylococcus aureus (MRSA) Drugs Be the First Line of Defense for Treatment of Abscesses Regardless of Location or Etiology? A confounding variable in the identification and treatment of orbital infection is recognizing and managing a multidrug-resistant offending agent. Traditionally, MRSA is suspected only after administration of common, broadspectrum antibiotics with more palatable safety profiles
Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 22, 2015
4
Clinical Pediatrics
provide no resolution. Reservation to prescribing MRSA drugs is justified because of the low-risk, yet damaging, side effects associated with them—for example, StevensJohnson syndrome or Clostridium difficile infection. Given the high correlation between upper-respiratory and/or sinus disease and orbital cellulitis and other ocular infection, Mathias et al8 have previously suggested that the absence of these associations could be used as a predictive factor suggesting a methicillin-resistant pathogen prior to the use of any pharmaceutical. It is the opinion of the authors that unilateral presentation is additional support for this suspicion. If the prevalence of MRSA continues, drugs with ORSA coverage, such as vancomycin, clindamycin, or sulfamethoxazole, may become the appropriate initial medical therapy.
Should Cultures Be Taken on Every Abscess Patient? Culturing is not common practice in typical eye care settings.9 The majority of ocular infectious events is superficial and uncomplicated. Therefore, culturing has become a procedure reserved for conditions that do not have a timely response to traditional therapy, have immediate visual debilitating implications, or result in the formation of a subperiosteal abscess that requires drainage because of the lack of antimicrobial penetrance. It is reasonable to justify the lack of culturing for preseptal cellulitis, given the questionable yield a clinician would receive from obtaining only a conjunctival swab. However, if an abscess requires drainage and intravenous antibiotics, culturing is expected. When a culture is obtained, it is imperative that the clinician understand that there are many endogenous microorganisms in and around the orbit. A negative culture from the lab does not necessarily indicate the absence of microbial growth on an agar dish but rather identifies expected microbes in their usual concentration. A positive culture identifies either an atypical agent in any concentration or unusual concentration of normal flora. Therefore, it is the responsibility of the clinician to know the resident flora of the eye and understand how each lab reports its findings before deciding on a monomicrobial or polymicrobial cause, if they choose to culture.9
Should Radiological Imaging Be Reserved Only for Orbital and Not Preseptal Cellulitis Patients? Radiological imaging of abscess formation is critical in determining the extent of disease migration. Infection of the globe would imply containment of the microorganism
within the confines of the Tenon’s capsule, whereas an orbital infection includes invasion into the orbital bone, soft tissue, muscles, and/or nerve. Being more specific, preseptal cellulitis is inflammation/infection anterior to the septum extending from the periosteum of the orbital rim to the tarsal plate of the eyelids. A preseptal location of infection is much more common, less invasive, and more manageable than that of orbital cellulitis, making the indication for imaging less likely. However, imaging is required when there is ocular displacement resulting from potential abscess formation. Radiological imaging of this patient did not provide data on the origin of infection, though it did confirm the presence of the lacrimal abscess. The frontal sinus is assumed to be the source of infection, with migration coming through the dehiscence found in the middle to outer third of the sinus floor. The significance of immediate treatment comes from the understanding of rapid contiguous spread of infection through the ophthalmic venous system—hence the use of Penrose tube drainage and MRSA antimicrobial agents. We could speculate that the recurrent nature of his hordeola was the culprit, though the time frame of last recurrence and their previous self-limiting nature complicated this issue.
Conclusion MRSA infections are commonly known to occur in hospitals or other health care environments. Among the pediatric population, MRSA infections are rapidly on the rise. One cross-sectional study reports that MRSA increased from 4.1% in 1998-1999 to an alarming 16.7% in 2005-2006.10 This is a dramatic increase in the incidence of MRSA infections over a period of less than a decade. The first reported, documented case of dacryoadenitis associated with MRSA was in 2008, and MRSA infections in pediatric populations have been increasing dramatically, as evident in the literature since that time.8,11 This case illustrates the susceptibility of the pediatric and adolescent population to MRSA infections within the orbit as the primary infection site. For this case, initial treatment for the dacryoadenitis was the use of oral Augmentin, a β-lactamase inhibiting drug. As demonstrated, this broad-spectrum antibiotic proved to be ineffective, resulting in increased edema of the eyelid and chemosis of the temporal conjunctiva, thus necessitating additional cellulitis workup. As previously mentioned, this case is unique in that it presents clinical characteristics that serve somewhat as predictive indicators, implicating a drug-resistant agent prior to culturing or the selection of Augmentin for initial treatment. First, the condition was unilateral, diminishing the probability of
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Sayani and Smith a systemic inflammatory cause. Second, the progression of the clinical signs was very aggressive. And third, sinus disease or antecedent upper-respiratory infections usually associated with orbital cellulitis cases were absent. As bacteria continue to evolve, they develop mechanisms to counter advances in our modern antibiotic therapies. Collectively, these evolving bacteria are known as MRSA.12 On diagnosis of this lacrimal gland abscess, same-day surgical excision and drainage of the abscess was critical because over time, an abscess poses the risk of emptying into the orbit and, ultimately, into the brain, which would be potentially life threatening. The intravenous antibiotic treatment with clindamycin and ceftriaxone in the case of a methicillin- or oxacillin-resistant S aureus infection is supported in the literature and is the treatment of choice for MRSA/ORSA infections.13,14 In medical offices, early suspicion for or detection of atypical pathogens, use of appropriate antibiotics, and conservative consultative care is critical in the care of these patients. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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