Sunday, April 29, 2007

Facial Cellulitis by Pseudomonas aeruginosa

Facial Cellulitis by Pseudomonas aeruginosa

from Cancer Control: Journal of the Moffitt Cancer Center
Causes of Head and Neck Lesions During Neutropenia
Orbital Cellulitis

Orbital cellulitis is most commonly caused by Staphylococcusaureus, Streptococcus sp, and anaerobic bacteria. In children,Haemophilus influenzae type B was the most common cause of head and neck cellulitis.[9] With theH. influenzae type B vaccination,non-type B H. influenzae is now more common. In addition to these pathogens, P. aeruginosacan cause orbital cellulitis. In cancer patients, especially those with lymphoma or leukemia, Aspergillussinusitis spreading to the orbit is the most common organism associated with orbital cellulitis.[10] Other predisposing factors include surgery, trauma, pre-existing ocular disease, and immunosuppressive therapy.[11] Affected patients usually present with acute onset of unilateral periorbital pain, redness, edema,warmth, and tenderness. This life-threatening infection should be treated promptly and aggressively with anti-staphylococcal and two antipseudomonal antibiotics,[12] and amphotericin B or a lipid formulation of amphotericin B if fungal sinusitis is suspected.

Lingual Cellulitis

Lingual cellulitis is extremely rare.[13] If it occurs in neutropenic patients, the inflammation and associated swelling of the soft tissue can advance quickly. Prompt surgical and medical management are required to prevent local progression.This has been reported in profoundly neutropenic patients with acute myeloblastic leukemia.[13] It may occur after minor local trauma,followed by infections with organisms colonizing the mouth.Anaerobic streptococci and pseudomonas have been isolated from blood cultures.


Tonsillitis in the setting of neutropeniais most commonly caused by anaerobic bacteria such as Capnocytophagaochracea and Fusobacteriumsp. Usually, this entity is diagnosed only when blood cultures are positive because anaerobic cultures of the oropharynx cannot be obtained without a tissue biopsy. The treatment of choice is a penicillin-containing antibiotic orclindamycin.

Cryptococcus neoformans usually causes chronic meningitis or pneumonia, or it can be completely asymptomatic early in the course.[14] One case of cryptococcal tonsillitis in a patient with chronic lymphocytic leukemia was reported.[15] He presented with left tonsillar enlargement without exudate. Blood cultures and excisional biopsy of the involved tonsil revealed the presence of C.neoformans. He was successfully treated with amphotericin B and flucytosine for 6 weeks.

Malignant Otitis

ExternaMalignant otitis externa is a serious, locally invasive Pseudomonasinfection that typically occurs in elderly diabetic patients.[16,17] Severe otalgia is the usual presenting complaint. Purulent drainage and granulation tissue in the external auditory canal are usually found on examination.Local cellulitis and bone destruction are best documented by computed tomography scan or magnetic resonance imaging techniques.Malignant otitis externa has been reported in three severely neutropenic children with acute lymphoblastic leukemia who were receiving induction chemotherapy.[18] All of them presented with pain, extensive soft-tissue involvement, and profound discharge.External ear canal cultures showed prolific growth of P. aeruginosaand S. aureus. They we retreated with a 2-week regimen of intravenous antibiotics and regular suctioning and washing of the canal to remove debris and necrotic tissue. Although rare, externalotitis with local extension into the mastoid due to Aspergillus infection can occur in patients with prolonged neutropenia.

Ramsay Hunt Syndrome

Ramsay Hunt syndrome is caused by reactivation of the latent varicella-zoster virus infection harbored in the geniculate ganglion.[19] It is most common in immunocompromised patients, usually presenting with vesicles over the pinna and external auditory meatus, facial nerve palsy, and auditory involvement(tinnitus, vertigo, and deafness).It has been reported recently in a patient with malignant granulosa cell tumor of the ovary who developed Ramsay Hunt syndrome following aggressive chemotherapy.[20] She presented with classical symptoms and signs. Tzanck smear from the vesicular lesions showed acantholytic and inflammatory cells with an occasional binucleated pattern suggesting herpes zoster virus.She was treated with high-dose acyclovir.Skin lesions and pain rapidly resolved, but facial paralysis persisted partially. Risk factors for reactivation varicella infection include radiation therapy, chemotherapy,and corticosteroid use as well as the underlying malignancy.

Acute Bilateral Parotitis

Acute bacterial parotitis typically occurs in elderly, dehydrated,intubated, or postoperative patients.The most common pathogen associated with acute parotitisis S. aureus, followed by viridans streptococci.[21] However, acute parotitis resulting from anaerobes,enteric Gram-negative bacilli, and P.aeruginosa has also been documented.[22,23] Patients usually present with pain, swelling, and dysphagia.On examination,symptoms include tense swelling over the parotid area, tenderness, and pain on opening the mouth. In cancer patients, the occurrence of acute bilateral parotitis may not be related to an infectious agent but can be caused by chemotherapy.Chemotherapy-induced acute parotitis occurred in three patients with acute myeloid or lymphoblastic leukemia who were being treated with L-asparaginase, daunorubicin,or cytarabine.[24-26] The parotitis persisted throughout chemotherapy administration and resolved promptly upon discontinuation of the drugs.

Leukemic Infiltration

Cutaneous involvement in certain types of leukemia is not uncommon. An unusual case of leukemic infiltration of the skin secondary to acute myeloblastic leukemia mimicking cellulitis has been reported.[27] The patient presented with bilateral periorbitaledema and erythema clinically simulating infectious periorbital cellulitis.Pathologic evidence of polymorphonuclear leukocyte infiltrate in the dermis suggested the presence of pyoderma gangrenosum, a condition that has been shown to coexist with leukemic infiltration.[28]


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