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Archives of Disease in Childhood Apr 2024To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections.
OBJECTIVE
To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections.
DESIGN
Multi-centre observational cohort study using data from 2009 to 2018 clinical records.
SETTING
Canadian children's hospitals (7) and community hospitals (3).
PATIENTS
Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections.
INTERVENTIONS
Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation.
MAIN OUTCOME MEASURES
Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates.
RESULTS
Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4-9.9). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018.
CONCLUSIONS
Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.
PubMed: 38589203
DOI: 10.1136/archdischild-2023-326175 -
Indian Journal of Otolaryngology and... Apr 2024Peri-apical infection is a prevalent form of odontogenic infection, typically following the path of least resistance through cancellous bone towards the cortical plate....
Peri-apical infection is a prevalent form of odontogenic infection, typically following the path of least resistance through cancellous bone towards the cortical plate. This infection begins as cellulitis and may progress to an abscess, sometimes involving various anatomically potential spaces. While frontal space infection is a rare complication of odontogenic infection spread, it can occur in conjunction with buccal space, sub-mental space, and orbital space involvement. In this report, we present the case of a 62-year-old man with a history of tooth pain and diabetes mellitus for the past decade. The patient exhibited symptoms of swelling, multiple draining sinuses, pain, proptosis, and fever. Prompt action was taken to drain the multiple abscesses, and the causative teeth were subsequently extracted. This case illustrates one of the severe complications associated with odontogenic infection, which has the potential to be life-threatening.
PubMed: 38566670
DOI: 10.1007/s12070-023-04421-w -
International Medical Case Reports... 2024Mucormycosis is a potentially fatal condition with a high mortality rate, particularly when there is extra nasal involvement, and it is rare for patients with fungal...
Mucormycosis is a potentially fatal condition with a high mortality rate, particularly when there is extra nasal involvement, and it is rare for patients with fungal brain disease to survive. It mostly affects patients who are metabolically or immunologically compromised, which constitutes one of the three classical stages of the progression of Rhino-Orbito-Cerebral Mucormycosis (ROCM). Stage I: infection of the nasal mucosa and paranasal sinuses; Stage II: orbital involvement; Stage III: cerebral involvement.Here, we report a case of rhino-orbital cerebral mucormycosis in a 14-year-old girl with no known risk factor who presented with periorbital edema, right eye proptosis, fever, and extreme facial pain, which progressively worsened to confusion and left leg weakness in 3 days after admission. The final diagnosis was rhino-orbital-cerebral mucormycosis. The infection was successfully treated using liposomal amphotericin and surgical debridement to remove infected orbital tissue. Mucormycosis is a potentially fatal disease that necessitates prompt diagnosis and treatment. Children are rarely infected with mucormycosis. The majority of studies show that people are typically between 40 and 50 years old. ROCM is typically diagnosed using clinical symptoms and histopathologic evaluation; however, imaging is critical in determining the presence of intracranial lesion. The standard treatment for ROCM is amphotericin B at a recommended dose of 1.0-1.5 mg/kg/day for weeks or months, depending on the clinical response and severity of adverse drug reactions, particularly nephrotoxicity.Rhino-orbital cerebral mucormycosis in a healthy female child is uncommon; early diagnosis and prompt treatment with Amphotericin B should be necessary. Devastating consequences will result from a delayed diagnosis.
PubMed: 38559497
DOI: 10.2147/IMCRJ.S454697 -
Ocular Immunology and Inflammation Mar 2024The current study queries the American Academy of Ophthalmology (AAO) Intelligent Research in Sight (IRIS) registry for data on the epidemiology, work-up, and management...
PURPOSE
The current study queries the American Academy of Ophthalmology (AAO) Intelligent Research in Sight (IRIS) registry for data on the epidemiology, work-up, and management patterns of autoimmune orbital inflammation.
METHODS
Analysis and description of patient data from the IRIS registry between 2013 and 2019 reviewing patients with autoimmune or idiopathic orbital inflammation with filters based on International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes. Patients with thyroid eye disease, orbital cellulitis, and orbital abscess were excluded.
MAIN OUTCOME MEASURES
Demographic descriptions included gender, age, geographic region, and treatment. Sub-analysis was performed by assessing rates of imaging, biopsy, lab work-up, and diagnostic categories.
RESULTS
In a final cohort of 20,584 patients, the mean age of onset of orbital inflammation was 51.7 years; 67% female; and 63% Caucasian, 21% unknown, 12% Black, 2.6% Asian, and 1.5% other. Only 49 had imaging, 78 had laboratory work-up, and 1,411 had biopsy codes. Treatment results showed 166 patients receiving antibiotics, 224 patients receiving steroids, and 35 patients receiving both.
CONCLUSIONS
This study assessed the epidemiology, diagnostic patterns, and treatment patterns for orbital inflammation through the AAO IRIS registry. Practise patterns suggest a relatively low overall rate of imaging and laboratory studies compared to biopsies, although this certainly under-represents the actual number of imaging and laboratory studies and exemplifies the inherent imprecision of using a large database. However, the methodology of this study provides a framework of approaching the IRIS registry for oculoplastic research.
PubMed: 38489590
DOI: 10.1080/09273948.2024.2322013 -
Frontiers in Pediatrics 2024Inborn errors of immunity (IEI) can often be misdiagnosed early in life due to their heterogenous clinical presentations. Interleukin-1 receptor-associated kinase 4...
Inborn errors of immunity (IEI) can often be misdiagnosed early in life due to their heterogenous clinical presentations. Interleukin-1 receptor-associated kinase 4 (IRAK-4) deficiency is one of the rare innate immunodeficiency disorders. We present the case of a patient who presented at the age of 15 days with meningitis and septic shock that responded to antibiotics. She was admitted again at the age of 45 days with bacteremia that was associated with increased inflammatory markers. Her third admission was at the age of 2.5 months due to left sided peri-orbital cellulitis that was again associated with elevated inflammatory markers. At 3.5 months, she experienced left orbital cellulitis, which was complicated by extensive sinus involvement, erosion, and abscess formation in the pterygopalatine fossa. Her condition progressed to septic shock and required multiple antibiotics and surgical interventions for drainage and control of the infection source. Both abscess and blood culture were positive for . An IEI was suspected but basic immunology testing was normal. Whole Exome Sequencing was performed and a novel mutation in IRAK4 was detected. In conclusion, we highlight the importance of raising awareness among pediatricians about the potentially lethal IEI and the need to consult specialists when these diseases are suspected. Among them is IRAK-4 deficiency which can be diagnosed by sophisticated functional assays and/or genetic testing.
PubMed: 38487470
DOI: 10.3389/fped.2024.1340367 -
Emergency Medicine Australasia : EMA Mar 2024There is substantial practice variation in the management of cellulitis with limited prospective studies describing the course of cellulitis after diagnosis. We aimed to...
OBJECTIVE
There is substantial practice variation in the management of cellulitis with limited prospective studies describing the course of cellulitis after diagnosis. We aimed to describe the demographics, clinical features (erythema, warmth, swelling and pain), patient-reported disease trajectory and medium-term follow-up for ED patients with cellulitis.
METHODS
Prospective observational cohort study of adults diagnosed with cellulitis in two EDs in Southeast Queensland, Australia. Patients with (peri)orbital cellulitis and abscess were excluded. Data were obtained from a baseline questionnaire, electronic medical records and follow-up questionnaires at 3, 7 and 14 days. Clinician adjudication of day 14 cellulitis cure was compared to patient assessment. Descriptive analyses were conducted.
RESULTS
Three-hundred patients (mean age 50 years, SD 19.9) with cellulitis were enrolled, predominantly affecting the lower limb (75%). Cellulitis features showed greatest improvement between enrolment and day 3. Clinical improvement continued gradually at days 7 and 14 with persistent skin erythema (41%) and swelling (37%) at day 14. Skin warmth was the feature most likely to be resolved at each time point. There was a discrepancy in clinician and patient assessment of cellulitis cure at day 14 (85.8% vs. 52.8% cured).
CONCLUSIONS
A clinical response of cellulitis features can be expected at day 3 with ongoing slower improvement over time. Over one third of patients had erythema or swelling at day 14. Patients are less likely than clinicians to deem their cellulitis cured at day 14. Future research should include parallel patient and clinician evaluation of cellulitis to help develop clearer definitions of treatment failure and cure.
PubMed: 38481041
DOI: 10.1111/1742-6723.14401 -
Archives of Craniofacial Surgery Mar 2024A 76-year-old woman, initially thought to have a simple abscess on her right upper eyelid, presented to our department of plastic and reconstructive surgery. Enhanced...
A 76-year-old woman, initially thought to have a simple abscess on her right upper eyelid, presented to our department of plastic and reconstructive surgery. Enhanced three-dimensional facial computed tomography (CT) revealed an abscess on the right upper lid, with a pyomucocele present in the right frontal sinus, accompanied by bone erosion in the superior wall of the right orbit. Based on the results of the CT scan, we diagnosed an atypical Pott's puffy tumor (PPT) with an abscess on the upper lid originating from the frontal sinusitis. First, surgical incision and drainage were performed in our department, and a percutaneous vacuum drain was placed. To provide a more definitive treatment, endoscopic sinus surgery (ESS) was subsequently performed by otorhinolaryngologists. The patient was discharged without any complications 5 days after ESS. At a 1-year follow-up, no recurrence or notable neurological symptoms were observed. In the case we observed, the patient presented with an upper eyelid abscess and cellulitis, indicating possible orbital involvement. For such patients, a CT scan is necessary. Given the possibility of PPT, it is critical to perform a comprehensive differential diagnosis rather than defaulting to a straightforward approach involving abscess treatment.
PubMed: 38447589
DOI: 10.7181/acfs.2023.00465 -
Orbit (Amsterdam, Netherlands) Mar 2024Sarcoid-like reaction (SLR) has been reported in patients with solid tumor malignancies, lymphomas, and patients receiving immunotherapy. SLR is often incidentally found...
Sarcoid-like reaction (SLR) has been reported in patients with solid tumor malignancies, lymphomas, and patients receiving immunotherapy. SLR is often incidentally found during positron emission tomography/computed tomography scans as hilar and/or mediastinal lymphadenopathy. SLR has also been found in the lung, spleen, bone marrow, and skin. Biopsy of these lesions shows noncaseating granulomas. When systemic criteria are not met for sarcoidosis, these noncaseating granulomas are termed SLR. We present the first case in the literature of a case of orbital SLR in a patient with concomitant diffuse large B-cell lymphoma and inverted papilloma of the maxillary sinus. This case highlights the importance of including malignancy in the differential for the presence of a noncaseating granuloma in the orbit.
PubMed: 38441528
DOI: 10.1080/01676830.2024.2318765 -
Case Reports in Ophthalmological... 2024We present a rare case of a 39-year-old female with extramedullary relapse of acute myeloid leukaemia (AML) isolated to the left eye 2 months post allogeneic...
We present a rare case of a 39-year-old female with extramedullary relapse of acute myeloid leukaemia (AML) isolated to the left eye 2 months post allogeneic haematopoietic stem cell transplant. She initially presented with painless left eye erythema, swelling, and visual impairment. Initial ophthalmology review revealed conjunctival chemosis, raised intraocular pressure, and serous retinal detachments. She was initially treated for suspected orbital cellulitis with intravenous antibiotic and antifungal therapy but clinically progressed so was then treated with intravenous corticosteroids. One week later, she progressed to angle-closure glaucoma with development of a hypopyon and an enlarging subconjunctival mass. She proceeded to urgent subconjunctival biopsy and drainage of subretinal fluid which confirmed extramedullary relapse of AML. Notably, further investigation found no evidence of bone marrow or central nervous system relapse. She proceeded to localized radiotherapy with gradual resolution of the subconjunctival mass and serous retinal detachment and was for consideration of donor lymphocyte infusions and azacitidine therapy; unfortunately, she developed respiratory sepsis and passed away despite maximal efforts. This case represents a rare and unusual presentation of isolated ocular extramedullary relapse of AML and emphasises the importance of early ophthalmology involvement and tissue biopsy when there is high clinical suspicion of the disease.
PubMed: 38419918
DOI: 10.1155/2024/2235819