Tuesday, February 26, 2008

Orbital cellulitis after faden operation on the medial rectus

Orbital cellulitis after faden operation on the medial rectus

Strabismus. 2007 Oct-Dec

Armesto A, Ugrin MC.
Ophthalmology Department, Hospital Alemán, Buenos Aires, Argentina.

Keywords: Orbital cellulitis; strabismus surgery; ethmoid sinusitis; Faden operation; intravenous antibiotics

BACKGROUND: Orbital cellulitis after strabismus surgery is uncommon, may cause blindness and may lead to death. Very few cases have been described in detail due to the low incidence of this complication.

METHODS: We report the first case of orbital cellulitis following Faden operation on the medial rectus muscle. We believe that the infection was due to asymptomatic ethmoid sinusitis. Our case is compared with other cases previously reported.

RESULTS: A two-year-old boy was surgically treated for residual esotropia after two botulinum toxin A injections. Two days after surgery, signs of orbital cellulitis developed in his right orbit. CT-scan disclosed right ethmoid sinusitis that spread to the orbit after surgery. After intravenous antibiotic treatment, the infection resolved with full restoration of visual acuity and ocular motility.

CONCLUSION: Despite adequate measures to prevent infection, orbital cellulitis may complicate strabismus surgery. Patients must be instructed to recognize early symptoms of this severe infection and call the surgeon immediately. Diagnosis may be confirmed by CT-scanning of the orbits. Prompt treatment with intravenous antibiotics usually leads to full recovery.



Saturday, February 23, 2008

A case of herpes zoster presenting as orbital cellulitis

A case of herpes zoster presenting as orbital cellulitis

Al-Rikabi A, Trotter MI, Khan H, Raut VV.

Head and Neck Department, Russells Hall Hospital, Dudley Group of Hospitals, Dudley, UK. alikamil30@yahoo.com.

We presented an unusual case of ophthalmic herpes zoster masquerading as orbital cellulitis, resulting in delay in appropriate treatment. A 65-year-old woman presented with left periorbital pain and swelling of a week duration. Examination revealed periorbital edema and inflammation but no proptosis. The erythema extended onto the brow. There was no change in visual acuity and cranial nerve function was normal. She was apyrexial and all other parameters were within normal limits. The patient was admitted with an initial diagnosis of sinusitis with orbital cellulitis/dacryocystitis and intravenous co-amoxiclav and a non-steroidal anti-inflammatory drug were administered. The following day, there was little change in her condition with the ocular movements being normal and vision remaining unaffected. She was apyrexial but the periorbital swelling persisted. Computed tomography of the sinuses did not show sinusitis or a periorbital collection. The third day after admission and 10 days after the initial appearance of pain, vesicles appeared on the left forehead, which enabled a diagnosis of herpes zoster of the ophthalmic branch of the trigeminal nerve. She was then treated with acyclovir with a good result.

PMID: 18187989 [PubMed - in process]


Friday, February 22, 2008

Case Cluster of Necrotizing Fasciitis and Cellulitis Associated with Vein Sclerotherapy

Case Cluster of Necrotizing Fasciitis and Cellulitis Associated with Vein Sclerotherapy

Infectious Diseases
Volume 14, Number 1–January 2008

Hiu-Tat Chan,* Jillian Low,† Lorraine Wilson,† Owen C Harris,* Allen C Cheng,† and Eugene Athan†
*St. John of God Pathology, Geelong, Victoria, Australia, and †Barwon Health, Geelong, Victoria, Australia

To the Editor: Varicose vein sclerotherapy is a commonly performed cosmetic surgical procedure in which a sclerosing agent is injected into small varicose veins of the leg by using small gauge needles. It is regarded as a minor, safe procedure, usually performed in an office clinic (
1). We describe a cluster of infections with group A Streptococcus that was associated with throat carriage in a cosmetic surgeon.

In early December 2006, 3 patients were seen over a 10-day period at Geelong Hospital with infections following varicose vein sclerotherapy. All patients had undergone varicose vein sclerotherapy with polidocanol (Laurath-9; Aethoxysklerol, BSN Medical, Mount Waverley, Australia) at a clinic of a single cosmetic surgeon. The index patient (patient A) had toxic shock syndrome and necrotizing fasciitis of the treated legs. The 2 other patients (patients C and D) had multifocal cellulitis directly correlating to the injection sites. The time between sclerotherapy and disease onset was 1–2 days.

A case-patient was defined as a patient who had undergone sclerotherapy at the clinic and subsequently had infection directly related to the site of sclerosant injection. Events were dated from the day on which the index patient had her surgical procedure. We reviewed clinic notes and infection control procedures in conjunction with the Department of Human Services of the State Government of Victoria, Australia. Specimens, where available, were collected for culture from patients by the treating clinicians. A throat swab was taken from the cosmetic surgeon. Specimens were transported and cultured by using standard methods.

Figure. Days of procedures for infected and noninfected patients and their first manifestations of infection...

During the outbreak period, 44 patients had vein sclerotherapy with 3% polidocanol at the cosmetic surgeon's clinic. In addition to the 3 patients identified on admission to hospital, a fourth patient (patient B) sought treatment from her general practitioner for medical care for a postprocedure infection. All patients had procedures on day 1 or day 7 (
Figure); patients A and B were seen consecutively on day 1, and 2 patients were treated between patients C and D on day 7.

Patient A required surgical debridement, intravenous antimicrobial drugs, intensive care, and hyperbaric oxygen therapy. Intraoperative specimens taken from her during debridement cultured group A Streptococcus. Patients B, C, and D had cellulitis, but no specimens suitable for microbiologic diagnosis of cellulitis were taken for culture. Patient B was treated with oral antimicrobial agents as an outpatient. Patient C was admitted to hospital for intravenous antimicrobial therapy, and patient D showed no improvement on oral antimicrobial therapy as an outpatient and was subsequently admitted to hospital for intravenous antimicrobial agents.

Group A Streptococcus was isolated from a throat swab taken on day 16 from the cosmetic surgeon. He reported no upper respiratory tract infection symptoms before the outbreak. He also reported that antiseptic skin preparation was not routinely used during the procedures; nor were gloves used. However, alcohol hand rubs were used between patients. The surgeon had not changed his infection control procedures recently and had not been aware of any infective complications previously. Environmental surface swabs taken on day 14 from 3 different areas (procedural trolley, surgical spotlight, and examination couch) in the clinic during the assessment yielded no pathogenic organisms. The infection control assessment team noted overall cleaning, disinfection, and hand hygiene to be inadequate.

Decolonization of the surgeon was performed by using rifampicin 600 mg daily and amoxicillin 500 mg every 6 hours for 10 days, during which time the surgeon suspended surgical procedures. Recommendations were made regarding infection prevention practices; these were undertaken by the surgeon.

Although soft tissue infection following sclerotherapy may be underreported, large case series have not noted this complication in the past (
2,3); this finding suggests that any soft tissue infection following sclerotherapy should be investigated. These cases highlight the need for vigilance when considering infection control for minor procedures that take place outside of the support of hospital-based infection control services.

Soft tissue infections as complications following varicose vein sclerotherapy appear to be rare (
1–3). The Australian Aethoxysklerol study reported no cellulitis in 16,804 legs injected with the sclerosing agent, and superficial thrombophlebitis occurred at a rate of 0.08% at 2-year review (2). Likewise a multicenter registry with 22 European phlebology clinics reported no cellulitis or necrotizing fasciitis in 12,173 sessions (3).

Similarly, surgical site infections with Group A Streptococcus are uncommon. A multicenter survey of 72 centers worldwide reported all β-hemolytic Streptococcus (including Group A and Group G) accounted for less then 5% more then 4.5%
. A Canadian study reported invasive Group A Streptococcus infections following surgery in 1.1 cases per 100,000 admissions (6). Outbreaks have been infrequently described (5,7–10), and sources of colonization range from throat to anus and vagina.


We thank Rosemary Lester and Michelle Cullen for their input.



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The Australian polidocanol (aethoxysklerol) study: results at 2 years. Dermatol Surg. 1995;21:334–6.
Guex JJ, Allaert FA, Gillet JL, Chleir F.
Immediate and midterm complications of sclerotherapy: report of a prospective multicenter registry of 12,173 sclerotherapy sessions. Dermatol Surg. 2005;31:123–8.
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Mastro TD, Farley TA, Elliott JA, Facklam RR, Perks JR, Hadler JL, et al.
An outbreak of surgical-wound infections due to group A Streptococcus carried on the scalp. N Engl J Med. 1990;323:968–72.
Daneman N, McGeer A, Low DE, Tyrrell G, Simor AE, McArthur M, et al
Hospital-acquired invasive group A streptococcal infections in Ontario, Canada, 1992–2000. Clin Infect Dis. 2005;41:334–42.
Kolmos HJ, Svendsen RN, Nielsen SV.
The surgical team as a source of postoperative wound infections caused by Streptococcus pyogenes. J Hosp Infect. 1997;35:207–14.
Viglionese A, Nottebart VF, Bodman HA, Platt R
Recurrent group A streptococcal carriage in a health care worker associated with widely separated nosocomial outbreaks. Am J Med. 1991;91:329S–33S.
Paul SM, Genese C, Spitalny K.
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Schaffner W, Lefkowitz LB Jr, Goodman JS, Koenig MG.
Hospital outbreak of infections with group A streptococci traced to an asymptomatic anal carrier. N Engl J Med. 1969;280:1224–5.


Monday, February 18, 2008

Lymphatic abnormalities demonstrated by lymphoscintigraphy after lower limb cellulitis.

Lymphatic abnormalities demonstrated by lymphoscintigraphy after lower limb cellulitis.

Br J Dermatol. 2008 Jan 30

Soo JK, Bicanic TA, Heenan S, Mortimer PS.

Department of Dermatology, St George's Hospital, Blackshaw Road, London SW17 0QT, UK.


Cellulitis is a common cause for admission to hospital, and repeated episodes are thought to damage the lymphatic system. Lymphoedema is recognized as a condition predisposing to cellulitis but there are no data to suggest its prevalence among a population presenting to hospital with acute cellulitis. Objectives To ascertain whether lymphatic abnormalities represent a common problem in patients with lower limb cellulitis.


Patients admitted with cellulitis of the lower limb were invited to undergo clinical examination and lymphoscintigraphy. Results Thirty patients agreed to participate in the study. Fifteen underwent lymphoscintigraphy. Thirteen had abnormal scans indicating impaired lymph drainage (seven patients had clinical lymphoedema).


Lymphatic abnormalities represent an important but unrecognized problem in patients with leg cellulitis.

Blackwell Synergy


Saturday, February 16, 2008

Acute Bacterial, Nonnecrotizing Cellulitis in Finland: Microbiological Findings

Acute Bacterial, Nonnecrotizing Cellulitis in Finland: Microbiological Findings
Clin Infect Dis. 2008 Feb 8

Siljander T, Karppelin M, Vähäkuopus S, Syrjänen J, Toropainen M, Kere J, Vuento R, Jussila T, Vuopio-Varkila J.
Departments of 1Bacterial and Inflammatory Diseases and 2Vaccines, National Public Health Institute, and 3Department of Medical Genetics, University of Helsinki, Helsinki, and 4Department of Internal Medicine and 5Centre for Laboratory Medicine, Tampere University Hospital, and 6Hatanpää City Hospital, Tampere, Finland; and 7Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden.


Bacterial, nonnecrotizing cellulitis is a localized and often recurrent infection of the skin. The aim of this study was to identify the beta-hemolytic streptococci that cause acute nonnecrotizing cellulitis infection in Finland.


A case-control study of 90 patients hospitalized for acute cellulitis and 90 control subjects was conducted during the period of April 2004-March 2005. Bacterial swab samples were obtained from skin lesions or any abrasion or fissured toe web. Blood culture samples were taken for detection of bacteremia.

The patients, their household members, and control subjects were assessed for pharyngeal carrier status. beta-Hemolytic streptococci and Staphylococcus aureus were isolated and identified, and group A and G streptococcal isolates were further analyzed by T serotyping and emm and pulsed-field gel electrophoresis typing.


Beta-Hemolytic streptococci were isolated from 26 (29%) of 90 patients, 2 isolates of which were blood-culture positive for group G streptococci, and 24 patients had culture-positive skin lesions. Group G Streptococcus (Streptococcus dysgalactiae subsp. equisimilis) was found most often and was isolated from 22% of patient samples of either skin lesions or blood, followed by group A Streptococcus, which was found in 7% of patients. Group G streptococci were also carried in the pharynx of 7% of patients and 13% of household members but was missing from control subjects. Several emm and pulsed-field gel electrophoresis types were present among the isolates. Six patients (7%) had recurrent infections during the study. In 2 patients, the group G streptococcal isolates recovered from skin lesions during 2 consecutive episodes had identical emm and pulsed-field gel electrophoresis types.


Group G streptococci, instead of group A streptococci, predominated in bacterial cellulitis. No clear predominance of a specific emm type was seen. The recurrent nature of cellulitis became evident during this study.

PMID: 18260753 [PubMed - as supplied by publisher]


Sunday, February 03, 2008

Odontogenic orbital cellulitis

Odontogenic orbital cellulitis

Ophthal Plast Reconstr Surg. 2008 Jan-Feb

Youssef OH, Stefanyszyn MA, Bilyk JR.
Wills Eye Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.


To describe a small series of patients with odontogenic orbital cellulitis and review the visual outcomes of such patients reported in the scientific literature.

METHODS: Review of medical records and the scientific literature. Measured parameters included gender, age, days to presentation and surgery, the need for surgical intervention(s), sinus and orbital involvement on CT imaging, and pathogens involved.

RESULTS: Current cases and review of the scientific literature resulted in 24 patients with odontogenic orbital cellulitis and adequate examinations for statistical analysis. Twelve of 24 patients had preserved vision (final vision better than 20/70), whereas 11 of 24 patients had vision loss (final vision of light perception or no light perception). Analysis of data showed no statistical correlation between visual loss and age (p = 0.81), days to clinical presentation (p = 0.45), days to surgical exploration (p = 0.96), sinus radiographic involvement (p = 0.50), orbital radiographic findings (p = 0.19), or type of bacterial infection (Gram-positive aerobic vs. anaerobic organisms), (p = 0.31 and p = 0.50 respectively). Male gender, the need for surgical drainage, and multiple surgical procedures performed correlated statistically with loss of vision (p = 0.05, p = 0.03, and p = 0.02, respectively).

CONCLUSIONS: Multiple case reports have demonstrated that orbital cellulitis from an odontogenic source can result in devastating visual loss. Male gender, the need for surgical drainage, and multiple surgical procedures correlated statistically with severity of visual loss.

Lippincott, Williams & Wilkins