Haemophilus influenzae periorbital cellulitis in a 95-year-old patient
Periorbital cellulitis (POC) is an acute bacterial infection of the eyelids. In the past, before the introduction of Haemophilus influenzae type B vaccination, POC was usually caused by this bacterium. Vaccination was introduced in 1985 and extended in 1990. Since then, most cases are caused by Staphylococcus aureus or Group A β-hemolytic Streptococcus. We present a case of POC caused by H. influenzae in a 95-year-old woman: to our knowledge, this is the oldest patient with POC reported in the literature.
Periorbital cellulitis (POC), or preseptal cellulitis, is an acute bacterial infection of the eyelids 1-15. In the past, before the introduction of Haemophilus influenzae type B vaccination, POC was usually caused by this bacterium. In the United States, vaccination was introduced in 1985 and extended in 1990. Since then, most cases are caused by Staphylococcus aureus or Group A b-hemolytic Streptococcus. We present a case of POC caused by H. influenzae in a 95-year-old woman: to our knowledge, this is the oldest patient with POC reported in the literature.
A 95-year-old Caucasian woman was admitted with a clinical diagnosis of herpes zoster. Her son stated that the dermatitis appeared suddenly three days before. It was diagnosed by the patient’s general practitioner as herpes zoster. A therapy with valacyclovir (3 g/day) was started. Dermatological examination showed a severe erythematous edema, with tiny round vesicles and pustules, at the left eyelids (Fig. 1). The consistency of the lesion was soft-parenchymatous. The patient complained of burning sensation, pain, and lachrymation.
General physical examination showed mild arterial essential hypertension. Left laterocervical lymphadenopathy was observed. Fever was 38.6°C. Ophthalmological examination was impossible because the patient could not open her left eye at all.
Laboratory tests showed leucocytosis with neutrophilia, and increase in erythrosedimentation rate and C-reactive protein. Blood culture was negative. Cytological examination of vesicles and pustules revealed the presence of cocci and excluded a herpetic infection. Swab obtained from pustular lesions was positive for Staphylococcus epidermidis. Culture of needle aspirate of the swelling was positive for H. influenzae. Nasal swab was positive for S. aureus. It was impossible to perform conjunctival swab. X-rays and computerized axial tomography of the head were negative. A diagnosis of POC was made. According to the antibiogram results, the patient was treated with ceftriaxone (2 g i.v. for 10 days): both H. influenzae and S. aureus were sensitive to this antibiotic. The clinical picture improved within three days. Complete remission was observed seven days later. Follow up (six months) was negative.
POC occurs almost exclusively in children 1-7,9,12-15 and is more frequent in males than in females 13,14. Cases in adults are extremely rare 8,10,11. Important predisposing factors of POC are local trauma 3,4,12,13. In two groups of patients, local trauma were responsible for penetration of bacteria in 20.9% 12 and 23.1% 13 of cases, respectively). Other risk factors are impetigo or adjacent focus of infection, otitis, conjunctivitis (in 42.9% of patients in the previously cited study 12), dacryostenosis 12, sinusitis 2,3,5,7,9,12,13 (observed from 8% 12 to 14.5% 9 to 19% 5 to 24.8% 13 to 81% 7 of patients), and upper respiratory tract infection 4,9,11. It is possible that in our patient the sudden appearance of the swelling was caused by an arthropod bite or sting: in the study by Rimon et al. 12, insect bites and stings were responsible for 9.8% of cases of POC. However, in our patient it was impossible to discover the source of H. influenzae.
In the past, the most frequently involved species in POC was H. influenzae 1-7,9,11,12. In United States, after the introduction in 1985 of vaccination for H. influenzae type B, the incidence of POC caused by this bacterium rapidly and deeply decreased 5,7,9,12,13,15. Other bacteria involved are S. aureus 2,3,15, Group A β-hemolytic Streptococcus 2,3,15, and Streptococcus pneumoniae 2,3. S. aureus and/or Group A β-hemolytic Streptococcus have been isolated also from conjunctival exudate as well as H. influenzae (in 13 out of 89 tear specimens in the study by Powell et al. 4). Blood culture of H. influenzae is often negtive 5-7. After the introduction of vaccination, H. influenzae positive blood cultures became ever more rare: 1 positive out of 34 patients 6 and 2 positive out of 133 cultures 7.
POC is characterized by the rapid appearance of usually monolateral erythematous edema, with smooth surface. The consistency is parenchymatous-hard. Sometimes, vesicles, blisters and pustules, as in our patient, appear. Local pain, fever, and general malaise are common. A dreadful complication is meningitis 1,5. Recurrences are possible. Laboratory tests show leukocytosis with neutrophilia and increase erythrosedimentation rate, C-reactive protein and α1-acid glycoprotein. Differential diagnosis includes orbital cellulitis, a severe infection involving the contents of the orbit, and herpes zoster. Therapy is based on systemic antibiotics, selected according the results of antibiogram, and incision and drainage 10.
Figures and tables
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