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 3 rd gen. Cephalosporin

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

15. Team Work EYE ENT ID NEUROSURGERY

18. 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. HEADS UP

19. Differential Dx. Proptosis 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

20. ANATOMY

22. Haemophilus Influenzae