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Interactive Journal of Medical Research Nov 2023Necrotizing fasciitis (NF) is an aggressive and potentially life-threatening infection of the superficial fascia and surrounding skin, fat, fascia, muscle, and other...
Necrotizing fasciitis (NF) is an aggressive and potentially life-threatening infection of the superficial fascia and surrounding skin, fat, fascia, muscle, and other soft tissue structures. Here, we outline the rare case of a 26-year-old man with a periorbital Streptococcus pyogenes A NF infection. Our case report underscores a unique instance of periorbital NF, distinctively presenting without any predisposing risk factors, shedding light on its presentation, treatment, and pathophysiology.
PubMed: 37971729
DOI: 10.2196/52507 -
Eye (London, England) Nov 2023To evaluate presenting features of patients with orbital solitary fibrous tumours (SFTs), based on histological phenotype.
AIMS
To evaluate presenting features of patients with orbital solitary fibrous tumours (SFTs), based on histological phenotype.
METHODS
A retrospective case-note review was performed for demographics and presenting features for patients with orbital SFTs. The tumours were classified as "Group IA" hypocellular SFT phenotype, "Group IB" haemangiopericytoma phenotype and low mitotic activity, and high-grade "Group II" haemangiopericytoma phenotype with high mitotic activity.
RESULTS
Sixty-four patients (34 female; 53%) presented at a mean age of 42.2 years (median 38; range 19-82), with Group II patients presenting at an older age (mean 53 years). Median symptom duration was 12 months for Groups IA and IB, compared to 4 months for Group II, the commonest symptoms being proptosis (53%), diplopia (41%), periorbital swelling (31%), and altered vision (19%). Mean LogMAR was 0.17 (median 0.0; range -0.2-4), and 14% had ipsilateral optic neuropathy, with no significant difference between the three groups. Non-axial displacement was noted in 69%, a palpable mass in 45%, and reduced eye movements in 59%; choroidal folds and optic disc swelling were recorded in 12% and 9%. SFTs were mostly extraconal (59%), within the superior and superonasal quadrants (44%), with an average estimated tumour volume of 4.9 ml (median 3.6; range 0.31-14.5 ml).
CONCLUSION
SFTs may present with impaired visual function (∼15%), fundal abnormalities (a fifth), globe displacement (two-thirds), and reduced ocular motility (over a half). High-grade tumours tend to present more than a decade later, with a shorter duration of symptoms.
Topics: Humans; Female; Adult; Retrospective Studies; Severe Fever with Thrombocytopenia Syndrome; Hemangiopericytoma; Solitary Fibrous Tumors; Exophthalmos
PubMed: 37061621
DOI: 10.1038/s41433-023-02519-7 -
Ophthalmic Plastic and Reconstructive...A 66-year-old immunocompromised man presented with cellulitis around the left eye that was initially concerning for necrotizing fasciitis. Exam findings were remarkable...
A 66-year-old immunocompromised man presented with cellulitis around the left eye that was initially concerning for necrotizing fasciitis. Exam findings were remarkable for exquisite periocular tenderness with rigid, immobile eyelids resulting from severe erythema, edema, and induration. Given the concern for orbital compartment syndrome and a necrotizing infection, the patient was taken urgently to the operating room for debridement of the eyelid skin as well as an urgent lateral canthotomy and cantholysis. His eye exam revealed 360° of hemorrhagic chemosis, no relative afferent pupillary defect, and an ipsilateral elevated intraocular pressure of 35 mm Hg. No visual acuity measurement could be obtained secondary to the patient's altered mental status. His intraocular pressure normalized after treatment with antihypertensive drops and further extension of the canthotomy. Histopathological analysis showed extensive neutrophilic infiltrate of the dermis which was compatible with a diagnosis of Sweet's syndrome.
Topics: Male; Humans; Aged; Intraocular Pressure; Sweet Syndrome; Orbit; Cellulitis; Eyelids
PubMed: 36893059
DOI: 10.1097/IOP.0000000000002373 -
Journal of General Internal Medicine Aug 2023Cellulitis is a clinical diagnosis with several mimics and no gold standard diagnostic criteria. Misdiagnosis is common. This review aims to quantify the proportion of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cellulitis is a clinical diagnosis with several mimics and no gold standard diagnostic criteria. Misdiagnosis is common. This review aims to quantify the proportion of cellulitis misdiagnosis in primary or unscheduled care settings based on a second clinical assessment and describe the proportion and types of alternative diagnoses.
METHODS
Electronic searches of Medline, Embase and Cochrane library (including CENTRAL) using MeSH and other subject terms identified 887 randomised and non-randomised clinical trials, and cohort studies. Included articles assessed the proportion of cellulitis misdiagnosis in primary or unscheduled care settings through a second clinical assessment up to 14 days post initial diagnosis of uncomplicated cellulitis. Studies on infants and patients with (peri-)orbital, purulent and severe or complex cellulitis were excluded. Screening and data extraction was conducted independently in pairs. Risk of bias was assessed using a modified risk of bias tool from Hoy et al. Meta-analyses were undertaken where ≥ 3 studies reported the same outcome.
RESULTS
Nine studies conducted in the USA, UK and Canada, including a total of 1600 participants, were eligible for inclusion. Six studies were conducted in the inpatient setting; three were in outpatient clinics. All nine included studies provided estimates of the proportion cellulitis misdiagnosis, with a range from 19 to 83%. The mean proportion misdiagnosed was 41% (95% CI 28 to 56% for random effects model). Heterogeneity between studies was very high both statistically (I 96%, p-value for heterogeneity < 0.001) and clinically. Of the misdiagnoses, 54% were attributed to three conditions (stasis dermatitis, eczematous dermatitis and edema/lymphedema).
DISCUSSION
The proportion of cellulitis misdiagnosis when reviewed within 14 days was substantial though highly variable, with the majority attributable to three diagnoses. This highlights the need for timely clinical reassessment and system initiatives to improve diagnostic accuracy of cellulitis and its most common mimics.
TRIAL REGISTRATION
Open Science Framework ( https://osf.io/9zt72 ).
Topics: Humans; Cellulitis; Diagnostic Errors; Canada
PubMed: 37231210
DOI: 10.1007/s11606-023-08229-w -
Cureus Oct 2023Neuroblastoma, a prevalent extracranial solid tumor commonly afflicting pediatric patients, exhibits a diverse spectrum of clinical presentations. Preseptal cellulitis,...
Neuroblastoma, a prevalent extracranial solid tumor commonly afflicting pediatric patients, exhibits a diverse spectrum of clinical presentations. Preseptal cellulitis, a childhood infectious ailment, typically demonstrates a favorable response to conservative antibiotic therapy. In this report, we present the case of a two-year-old female child with refractory preseptal cellulitis, ultimately leading to an unforeseen diagnosis of neuroblastoma. Early radiological assessment upon the onset of preseptal cellulitis serves the dual purpose of excluding severe complications and uncovering latent, rare pathologies when the initial antibiotic regimen proves ineffective.
PubMed: 38021563
DOI: 10.7759/cureus.47403 -
Rheumatology (Oxford, England) Sep 2023To compare clinical characteristics, including the frequency of cutaneous, extramuscular manifestations, and malignancy, between adults with anti-synthetase syndrome...
OBJECTIVES
To compare clinical characteristics, including the frequency of cutaneous, extramuscular manifestations, and malignancy, between adults with anti-synthetase syndrome (ASyS) and dermatomyositis (DM).
METHODS
Using data regarding adults from the MYONET registry, a cohort of DM patients with anti-Mi2/-TIF1ɣ/-NXP2/-SAE/-MDA5 autoantibodies, and a cohort of ASyS patients with anti-tRNA synthetase autoantibodies (anti-Jo1/-PL7/-PL12/-OJ/-EJ/-Zo/-KS) were identified. Patients with DM sine dermatitis or with discordant dual autoantibody specificities were excluded. Sub-cohorts of patients with ASyS with or without skin involvement were defined based on presence of DM-type rashes (heliotrope rash, Gottron's papules/sign, violaceous rash, shawl sign, V sign, erythroderma, and/or periorbital rash).
RESULTS
In total 1,054 patients were included (DM, n = 405; ASyS, n = 649). In ASyS cohort, 31% (n = 203) had DM-type skin involvement (ASyS-DMskin). A higher frequency of extramuscular manifestations, including Mechanic's hands, Raynaud's phenomenon, arthritis, interstitial lung disease, and cardiac involvement differentiated ASyS-DMskin from DM (all p< 0.001), whereas higher frequency of any of four DM-type rashes: heliotrope rash (n = 248, 61% vs n = 90, 44%), violaceous rash (n = 166, 41% vs n = 57, 9%), V sign (n = 124, 31% vs n = 28, 4%), and shawl sign (n = 133, 33% vs n = 18, 3%) differentiated DM from ASyS-DMskin (all p< 0.005). Cancer-associated myositis (CAM) was more frequent in DM (n = 67, 17%) compared with ASyS (n = 21, 3%) and ASyS-DMskin (n = 7, 3%) cohorts (both p< 0.001).
CONCLUSION
DM-type rashes are frequent in patients with ASyS; however, distinct clinical manifestations differentiate these patients from classical DM. Skin involvement in ASyS does not necessitate increased malignancy surveillance. These findings will inform future ASyS classification criteria and patient management.
PubMed: 37698987
DOI: 10.1093/rheumatology/kead481 -
Cureus Jul 2023Neurosarcoidosis (NS) is a rare manifestation of sarcoidosis, a multisystem inflammatory granulomatous disease. We describe a unique case of NS with confusion and speech...
Neurosarcoidosis (NS) is a rare manifestation of sarcoidosis, a multisystem inflammatory granulomatous disease. We describe a unique case of NS with confusion and speech alteration as presenting symptoms. A 65-year-old male with a history of Ramsay Hunt syndrome and Lyme infection presented to the emergency room after an acute episode of disorientation, garbled speech, and left facial droop, along with months of worsening generalized fatigue, gait ataxia, left-sided periorbital headaches, bilateral peripheral neuropathy, and bladder disturbance. A recent CT scan of his chest showed mediastinal lymphadenopathy, and a lymph node biopsy revealed non-necrotizing granulomas, Langhans giant cells, and focal Schaumann bodies. A brain MRI revealed a mildly enlarged anterior pituitary gland, mild prominent enhancement of the trigeminal nerves bilaterally, and right frontal, parietal, and superior temporal leptomeningeal enhancement. Lumbar puncture cerebrospinal fluid analyses were consistent with aseptic meningitis. A diagnosis of probable NS was made. The patient received IV methylprednisolone 1 g for three days, followed by a prednisone taper with clinical improvement. NS is a diagnostic challenge due to the variability of clinical presentations of the disease. This case demonstrates how vague chronic neurologic symptoms preceding an unusual acute clinical presentation delayed the diagnosis of NS in a patient with sarcoidosis.
PubMed: 37641764
DOI: 10.7759/cureus.42627 -
Cureus Nov 2023The authors present the case of a 39-year-old male who presented to the hospital with worsening eye pain, swelling, and blurred vision of the left eye. His symptoms grew...
The authors present the case of a 39-year-old male who presented to the hospital with worsening eye pain, swelling, and blurred vision of the left eye. His symptoms grew worse despite initial over-the-counter medication and a trip to the urgent care center. A physical exam was concerning for a possible orbital cellulitis given the appearance of the eye and the amount of discomfort, as well as their immunocompromised status, necessitating imaging and workup to confirm the diagnosis. The patient was ultimately diagnosed with periorbital cellulitis and bacterial conjunctivitis, and he received intravenous antibiotics for treatment. This case underscores the importance of a comprehensive diagnostic approach to managing ocular infections.
PubMed: 38074053
DOI: 10.7759/cureus.48439 -
Scientific Reports Oct 2023Molluscum contagiosum presenting as a periorbital region abscess is unusual. The virus generally causes a self-limiting localized disease in children. Presentation as an...
Molluscum contagiosum presenting as a periorbital region abscess is unusual. The virus generally causes a self-limiting localized disease in children. Presentation as an abscess has been reported mainly in immunocompromised patients. We performed a retrospective study of ten children treated for Molluscum contagiosum infection presenting as periorbital abscess. Data investigated included age, immunocompetence, systemic antibiotic treatment, clinical findings, and histopathology. All children were immunocompetent. Bacterial cultures taken in six of the ten children were positive in two. Seven patients received oral antibiotics before presentation but required IV antibiotics on admission. One patient received IV antibiotics only. All antibiotic treatment had very limited effect. Two patients had no antibiotic treatment. CT imaging in one case where orbital cellulitis was suspected showed no significant intraorbital findings with anterior involvement only. Nine out of ten children had surgery and intra-operative cryotherapy at our center with immediate improvement and recovery. One child whose parents initially refused surgical excision had initial limited clinical improvement of periorbital swelling with antibiotics. However, the lesions were excised shortly following discharge from our hospital at another medical center with a complete cure. Molluscum is a cause of periorbital abscess in immunocompetent children which should be part of the differential diagnosis in periorbital/adnexal infection. Antibiotic treatment has a limited effect, and the abscess is most likely a virally triggered reaction. Surgical excision and intra-operative cryotherapy are curative of the disease in our experience.
Topics: Humans; Child; Molluscum Contagiosum; Abscess; Retrospective Studies; Eye Diseases; Anti-Bacterial Agents
PubMed: 37872236
DOI: 10.1038/s41598-023-45320-y -
The Journal of Craniofacial Surgery Sep 2023The authors report a case of an intraorbital wooden foreign body that was misinterpreted as a radiolucent area of retained air on a computed tomography (CT) scan. A...
The authors report a case of an intraorbital wooden foreign body that was misinterpreted as a radiolucent area of retained air on a computed tomography (CT) scan. A 20-year-old soldier presented to an outpatient clinic following an impingement with a bough while cutting down a tree. He had a 1-cm-deep laceration on the inner canthal area of his right eye. A military surgeon explored the wound and suspected a foreign body, but could not find or extract anything. Thereafter, the wound was sutured and the patient was transferred. An examination revealed an acutely ill-looking man with distressing pain in the medial canthal and supraorbital area associated with ipsilateral ptosis and periorbital edema. A CT scan showed a radiolucent area suspected to be retained air in the medial periorbital area. The wound was explored. Upon removal of the stitch, yellowish pus was drained. An intraorbital piece of wood measuring 1.5 cm×0.7 cm was extracted. The patient's hospital course was uneventful. Pus culture revealed growth of Staphylococcus epidermidis . Wood has a density similar to air and fat and can be difficult to distinguish from soft tissue both on plain x-ray films and CT. In this case, the CT scan showed a radiolucent area resembling retained air. Magnetic resonance imaging is a better method of investigation in cases of a suspected organic intraorbital foreign body. Clinicians should be aware of the possibility of retention of an intraorbital foreign body in patients presenting with periorbital trauma, especially those with even a small open wound.
Topics: Male; Humans; Young Adult; Adult; Eye Foreign Bodies; Military Personnel; Foreign Bodies; Tomography, X-Ray Computed; Eye Injuries, Penetrating; Wood; Lacrimal Apparatus; Suppuration; Orbit
PubMed: 37317002
DOI: 10.1097/SCS.0000000000009482