Saturday, June 17, 2006

Periorbital cellulitis with breast cancer

Roger J G Stevens, MB MSc, Jennifer E Rusby, MA MRCS, and Michael D Graham, MChir FRCS

Department of Surgery, Dorset County Hospital, Dorchester Dorset DT1 2JY, UK

Correspondence to: Mr Michael D Graham E-mail: rjgs@doctors.org.UK

Periorbital cellulitis is a condition frequently referred to general physicians rather than ophthalmologists. It can be caused by malignant disease.
Case History

A woman of 50 reported two months of left facial swelling associated with pain and paraesthesia. She had diabetes and was on anticoagulants after a complicated lower limb arterial reconstruction for peripheral vascular disease. Two days before admission she had felt generally unwell and developed periorbital cellulitis and fever with poor glycaemic control.

Her temperature was 38°C, she had a sinus tachycardia of 120 beats per minute and a random blood glucose was 17 mmol/L. Periorbital swelling and erythema extending to the left side of her face was consistent with periorbital cellulitis. An incidental finding on examination was a 6 × 10 cm hard mass in the upper outer quadrant of the right breast with associated axillary lymphadenopathy and a left pleural effusion. C-reactive protein was 173 mg/L and she was hyponatraemic (sodium 125 mmol/L) and hypocalcaemic (calcium 1.97 mmol/L). Alkaline phosphatase was raised at 373 IuL. A chest radiograph confirmed a left pleural effusion. She was treated empirically with broad-spectrum intravenous antibiotics and chloramphenicol eye drops.

A CT scan of the brain and orbits (Figure 1) showed a large space-occupying lesion centred on the greater wing of the left sphenoid bone and increased attenuation of the soft tissues around the left eye consistent with periorbital cellulitis. A neurosurgical opinion was sought but biopsy of the lesion was considered inappropriate since this would have required complex surgery and would not have changed the management. Mammography revealed a 5 cm mass in the upper outer quadrant of the right breast, graded M5 with multiple satellite lesions and a 2 cm mass in the axillary tail. A core biopsy showed this to be an invasive ductal carcinoma, graded B5b. Oestrogen and progesterone receptor status was strongly positive. A technetium-99m whole body bone scan demonstrated increased uptake not only in the left sphenoid but also in several areas of the vertebral column and in the right sacroiliac joint, consistent with further metastases.

The cellulitis resolved with antibiotics. Current treatment is tamoxifen 20 mg once a day and the patient is being considered for primary palliative chemotherapy with or without local radiotherapy.

Comment

Orbital metastasis is well recognized by ophthalmologists, 1 but we can find no previous report of it causing periorbital cellulitis in which soft tissue inflammation is limited to the tissues anterior to the orbital septum (Figure 2). 2,3 Periorbital cellulitis is frequently associated with local trauma or with spread from upper respiratory tract infection and is common in children and in people with diabetes. 2 It usually resolves with intravenous antibiotics, but occasionally progresses posterior to the septum to become the more severe condition of orbital cellulitis3—which is occasionally due to orbital neoplasia. 4

Carcinoma of the breast is notorious for its diverse presentation. Metastases in bone and brain are common5 but the sphenoid is very seldom affected. In the largest retrospective review, of nearly 650 patients with orbital tumours, 2.5% were due to metastases, of which 75% originated from the breast, so that sphenoid metastasis from the breast accounted for just 1.8% of orbital space-occupying lesions. 1 In a subsequent review of 35 patients presenting with orbital metastasis, breast carcinoma was the primary tumour in 50% of cases, other less common sources being prostate, lung and the gastrointestinal tract. 6 In this and another series of a similar size, 7 the symptoms or signs of this metastasis were the first manifestation of the disease in about a quarter of the patients. Adults with periorbital cellulitis should always be questioned and examined for evidence of otherwise occult malignant disease. Involvement of an ophthalmologist is advisable.

References

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Mawn LA, Jordan DR, Donahue SP. Preseptal and orbital cellulitis. Ophthalmol Clin N Am 2000;13: 633-41.

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Oh KT, Alford M, Kotula RJ, Nerad JA. Adenocarcinoma of the esophagus presenting as orbital cellulitis. Arch Ophthalmol 2000;118: 986-8 [
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Patanaphan V, Salazar OM, Risco R. Breast cancer: metastatic patterns and their prognosis. South Med J 1988;81: 1109-12 [
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Shields CL, Shields JA, Peggs M. Tumors metastatic to the orbit. Ophthal Plast Reconstr Surg 1988;4: 473-80.

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Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology 1990;97: 620-4 [
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Journal of the Royal Society of Medicine

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