Thursday, March 27, 2008

Natural Killer/T-cell Lymphoma Masquerading as Orbital Cellulitis.

Natural Killer/T-cell Lymphoma Masquerading as Orbital Cellulitis.

Mar 2008 Ophthal Plast Reconstr Surg.

Charton J, Witherspoon SR, Itani K, Jones FR, Marple B, Morse B.
Departments of *Ophthalmology, †Otolaryngology, Head and Neck Surgery, and ‡Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.

We describe 3 cases of natural killer/T-cell lymphoma that presented by masquerading as orbital cellulitis. All of the patients were examined for pain, fever, proptosis, and motility restriction. Computed tomography of the orbits and sinuses revealed orbital soft-tissue swelling without focal abscess in all 3 cases. Bacterial and fungal cultures were negative in each case and all of the patients had initial improvement on systemic antibiotics, only to relapse several days later. Diagnosis of natural killer/T-cell lymphoma was then made based on biopsy of the orbit or sinus. Natural killer/T-cell lymphoma should be considered in cases of orbital cellulitis or sinusitis that fail to respond to traditional management. Biopsy of the affected region should be performed expeditiously to diagnose this condition. Repeat biopsy may be needed.

Lippincott, Wilkins & Williams

Orbital cellulitis or lymphoma? A diagnostic challenge.

J Laryngol Otol. 2005 Sep

Salam A, Saldana M, Zaman N.
Southampton Eye Unit, Southampton General Hospital, UK.

We present a case report of an aggressive natural killer T cell lymphoma in a police officer who presented with combined features of orbital cellulitis and mid-facial destruction. However, his initial diagnosis was confused with other disease conditions that had overlapping features. This emphasizes the significance of clinical alertness and adequate tissue sampling; this can have a great impact on early diagnosis and treatment.

PMID: 16156921 [PubMed - indexed for MEDLINE]

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Thursday, March 20, 2008

Moxifloxacin-Associated Neutropenia in a Cirrhotic Elderly Woman with Lower Extremity Cellulitis

Moxifloxacin-Associated Neutropenia in a Cirrhotic Elderly Woman with Lower Extremity Cellulitis

Ann Pharmacother. 2008 Mar

Chang CM, Lee NY, Lee HC, Lee IW, Wu CJ, Lin YS, Ko WC.
Divisions of Infectious Diseases, Geriatrics, and Gerontology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.

OBJECTIVE: To report a case of moxifloxacin-associated neutropenia in a cirrhotic patient with cellulitis.

CASE SUMMARY: A 77-year-old cirrhotic woman developed cellulitis of the right leg, with a nadir white blood cell (WBC) count of 1.5 x 103/microL and absolute neutrophil count (ANC) of 0.345 x 103/microL, which occurred after 5 days of moxifloxacin therapy. Moxifloxacin was switched to cefixime and neutropenia resolved 2 days after the withdrawal of moxifloxacin.

DISCUSSION: Cases of neutropenia related to fluoroquinolones have rarely been reported in the literature, and neutropenia associated with moxifloxacin has not been described before. Because of the temporal relationship between moxifloxacin administration and the development of neutropenia in our patient, as well as the relationship between drug withdrawal and improvement in WBC count and ANC, moxifloxacin-associated neutropenia was suspected. This reaction was categorized as probable according to the Naranjo probability scale.

CONCLUSIONS: We report the first case of moxifloxacin-associated neutropenia. Although such an adverse reaction is rare, clinicians should be aware of this potential complication of moxifloxacin therapy.

Annals of Pharmacotherapy

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Friday, March 14, 2008

Retrospective study of the clinical features of limb cellulitis in 63 horses

Retrospective study of the clinical features of limb cellulitis in 63 horses

Vet Rec. 2008 Feb 23

Fjordbakk CT, Arroyo LG, Hewson J.
Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario n1g 2w1, Canada.

A retrospective study of 63 horses diagnosed with limb cellulitis between 1994 and 2005 was conducted. They all had an acute onset of painful, generalised limb swelling, and a clinical diagnosis of limb cellulitis was made by the attending clinician. None of the horses had more than one limb affected. Hindlimbs were significantly more often affected than the forelimbs (P less then 0.05).

Veterinary Record

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Saturday, March 08, 2008

Cervical cellulitis and mediastinitis following esophageal perforation: A case report.

Cervical cellulitis and mediastinitis following esophageal perforation: A case report.

World J Gastroenterol. 2008 Mar

Righini CA, Tea BZ, Reyt E, Chahine KA.
Department of ENT-HNS, University Medical Center of Grenoble, 38043 Grenoble Cedex 09, France.

Chicken bone is one of the most frequent foreign bodies (FB) associated with upper esophageal perforation. Upper digestive tract penetrating FB may lead to life threatening complications and requires prompt management. We present the case of a 52-year-old man who sustained an upper esophageal perforation associated with cervical cellulitis and mediastinitis. Following CT-scan evidence of FB penetrating the esophagus, the impacted FB was successfully extracted under rigid esophagoscopy. Direct suture was required to close the esophageal perforation.

Cervical and mediastinal drainage were made immediately. Naso-gastric tube decompression, broad-spectrum intravenous antibiotics, and parenteral hyperalimentation were administered for 10 d postoperatively. An esophagogram at d 10 revealed no leak at the repair site, and oral alimentation was successfully reinstituted.

Conclusion: Rigid endoscope management of FB esophageal penetration is a simple, safe and effective procedure. Primary esophageal repair with drainage of all affected compartments are necessary to avoid life-threatening complications.

Key words: Esophagus; Perforation; Foreign body; Mediastinitis; Surgery

Peer reviewer: Michael F Vaezi, Department of Gastroenterology and Hepatology, Vanderbilt University Medical Center, 1501 TVC, Nashville, TN 37232-5280, United States

Righini CA, Tea BZ, Reyt E, Chahine KA. Cervical cellulitis and mediastinitis following esophageal perforation: A case report. World J Gastroenterol 2008; 14(9): 1450-1452 Available from:


Management of ingested foreign bodies (FB) is a common clinical encounter. Complications of this pathology are dependent on patient age, nature and localization of the FB, presence of a perforation, and initial management procedures[1]. Beside the lingual tonsils, the base of tongue and the upper esophagus are the most common sites of FB impaction[2]. The most frequent ingested FBs in the upper digestive tract are chicken and fish bones, and they are the most commonly associated with pharyngo-esophageal perforation[1], cervical abscess and potentially life threatening complications[3].


A 52-year-old man, with no relevant past medical history, presented to the ENT clinic complaining of severe dysphagia, substernal pain, and fever for 3 d. Five days prior to presentation, the patients started having symptoms of mild dysphagia after chewing on a piece of chicken. One day later on, exacerbation of dysphagia prompted the patient to seek otolaryngology consultation in town. Following seemingly normal head and neck examination, the patient was reassured and discharged. On admission at the University Medical center of Grenoble, the patient had a fever of 40℃ and mild shortness of breath. No abnormalities were noted on examination of the oropharynx, but the hypopharynx and larynx were swollen and there was abundant saliva in hypopharynx. The neck exam revealed bilateral anterior and lateral tenderness, inflammation and edema of the skin, and crepitation. On pulmonary auscultation, sparse rales were heard over the lower part of each hemi-thorax. Cardiac auscultation revealed a regular rhythm and normal heart sounds.

The patient had a white blood cell count of 20 × 109/L with 80% neutrophils and a C reactive protein level to 120 mg/L

A cervical and thoracic CT-scan revealed a fragment of bone in the upper part of esophagus, air in the retropharyngeal space and the upper part of the posterior mediastinum, and deep subcutaneous collection suggestive of cervical posterior mediastinal collection (Figure 1).

The patient was taken immediately to the operating room for surgical treatment under general anesthesia. Endoscopic examination was performed using a rigid endoscope (Storz f 16 mm - L 50 cm, Tuttlingen, Germany) which revealed meat fragments and a piece of chicken bone impacted in the upper esophageal wall, 19 cm from incisors. Meat fragments were aspirated using a 4 mm rigid aspiration; forceful pulling of the FB using forceps caused the edges of the FB to bend, enabling extraction through the rigid esophagoscope. After bone removal, a 4 mm perforation was visible at the site of impaction with pus draining through it. Gastric decompression via a naso-gastric tube was performed.

A large neck incision was required to drain the pus from cervical spaces (Figure 2), and the collection in the upper posterior mediastinum was evacuated through the same incision following retropharyngeal space dissection. The drainage of the neck abscess revealed a small bone fragment within the purulent discharge, and cultures were taken. The edges of the perforation were carefully derided and the entire surgical field was well irrigated. The defect was then closed in two layers using fine interrupted absorbable monofilament suture. Drainage of the neck and the upper mediastinum was done by placement of multi-tubular silicone drains through cervical incision. A temporary tracheotomy was performed to bypass the edematous larynx. Broad-spectrum intravenous antibiotics (imipeneme 2 g/d+ amikacine 1 g/d+ metronidazole 1 g/d), and parenteral hyperalimentation were started. The patient was admitted to the intensive care unit for 5 d. The patient medical status improved rapidly, and biological laboratory exams were normalized during the first post operative week. Tracheotomy and drains were removed at postoperative d 6 and d 8 respectively. An esophagogram performed at d 10 revealed no leak at the repair site, and oral alimentation was successfully reinstituted. Streptococcus b C hemolytic was isolated from the cultured pus, allowing for switching to amoxicillin and clavulanic acid 4 g/d at postoperative d 3, and continued for 7 d. The patient was discharged from the hospital in good condition on postoperative d 15.


The majority of ingested FBs pass through the gastrointestinal tract uneventfully[1]. Severe complications are rare, but upper digestive tract perforation is the most frequent. Among the esophageal perforation etiologies, FB represent the second most common etiology after iatrogenic manipulation (esophagoscopy, esophageal dilatation, para-esophageal surgery, external trauma)[4]. The diagnosis of esophageal perforation is usually suspected on clinical basis, and suggestive history of sharp bodies ingestion (chicken and fish bones)[5]. Symptoms include pain, dysphagia, and rarely hematemetis; pain is the most frequent symptom (> 90%)[5]. In case of upper esophagus perforation, tenderness and subcutaneous emphysema of the neck are the two main signs. Substernal pain and polypnea are signs associated with mediastinal extension[5]. In these cases, mediastinal crunch (Hamman sign) and crepitations are heard on chest auscultation[6]. Fever and leukocytosis with increase in the number of immature polymorphonuclear cells are present in more than 90% of patients[5].

Standard neck and chest radiograms are ordered if an esophageal perforation is suspected. But these exams reveal esophageal perforation in only a small proportion of cases[7]. Moreover, even if FB is radiopaque, it can be unrecognized because a lot of bone structures are superposed. The perforation diagnosis is confirmed in almost all cases by contrast esophagograms, which can delineate both the level of perforation and the communication of the injury into cervical and mediastinal spaces[6,7]. CT-scan allows the visualization of FB and the identification of findings suggestive of esophageal perforation (esophageal wall thickening and laceration, peri-esophageal air and fluid). Intravenous administration of contrast material helps CT-scan localization of the exact extension of peri-esophageal infection in the neck, mediastinal, and pleuro-parenchymal spaces[8]. Its sensitivity can be increased with gastrografin ingestion. Thus, an appropriate CT examination enables an accurate and timely diagnosis which significantly affects prognosis and provides valuable indications for treatment.

Extraction of FBs located in the first few centimeters under the upper esophageal sphincter, is difficult with a flexible esophagoscope, especially if they have sharp edges, such as bone fragments[9]. Rigid endoscopy may be a more appropriate procedure in these instances. The rigid endoscope is placed just above the proximal tip of the FB; it dilates the esophageal lumen to the extent that the impacted FB is movable. The use of a rigid endoscope during removal of an impacted FB has several advantages: it causes expansion of the upper esophagus, which can release totally or in part the impacted FB, and prevents aspiration and esophageal or pharyngeal injury. It must be practiced under general anesthesia by a trained operator.

Non-operative management is excluded in case of cervical and/or mediastinal abscesses[4]. Different surgical approaches are available for esophageal perforation, including primary repair with drainage, generally chosen for patients without evidence of a severe esophageal injury and without other esophageal disease[10]. A simple suture is recommended in case of small perforation in the cervical esophagus[5]. It is not necessary to use mucosal flaps to reinforce the esophageal sutures, contrarily to the recommendations for injuries of the middle and lower parts of esophagus[11]. In case of cervical abscess and/or mediastinitis, drainage of the different affected spaces must be done[12]. The choice of surgical approach for mediastinal drainage is dependent on abscess localization. In case of posterior and superior mediastinitis, drainage from cervical incision with retropharyngeal space dissection is adopted. Prognosis in case of upper esophageal perforation is relatively good with mortality inferior to 10%[5].

In conclusion, perforation of the upper esophagus caused by a FB is rare, but can cause potentially life threatening mediastinal complications. CT-scan enables accurate and timely diagnosis and provides valuable indications for treatment. Extraction of esophageal FB with a rigid endoscope is a good and safe treatment alternative. Non-operative management of esophageal perforation is not an option in the presence of neck and mediastinum abscesses and necessitates a surgical suture and drainage.


1 Selivanov V, Sheldon GF, Cello JP, Crass RA. Management of foreign body ingestion. Ann Surg 1984; 199: 187-191 PubMed
2 Chee LW, Sethi DS. Diagnostic and therapeutic approach to migrating foreign bodies. Ann Otol Rhinol Laryngol 1999; 108: 177-180 PubMed
3 Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004; 77: 1475-1483 PubMed
4 Altorjay A, Kiss J, Voros A, Bohak A. Nonoperative management of esophageal perforations. Is it justified? Ann Surg 1997; 225: 415-421 PubMed
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7 De Lutio di Castelguidone E, Pinto A, Merola S, Stavolo C, Romano L. Role of Spiral and Multislice Computed Tomography in the evaluation of traumatic and spontaneous oesophageal perforation. Our experience. Radiol Med (Torino) 2005; 109: 252-259 PubMed
8 Exarhos DN, Malagari K, Tsatalou EG, Benakis SV, Peppas C, Kotanidou A, Chondros D, Roussos C. Acute mediastinitis: spectrum of computed tomography findings. Eur Radiol 2005; 15: 1569-1574 PubMed
9 Seo YS, Park JJ, Kim JH, Kim JY, Yeon JE, Kim JS, Byun KS, Bak YT. Removal of press-through-packs impacted in the upper esophagus using an overtube. World J Gastroenterol 2006; 12: 5909-5912 PubMed
10 Cheynel N, Arnal E, Peschaud F, Rat P, Bernard A, Favre JP. Perforation and rupture of the oesophagus: treatment and prognosis. Ann Chir 2003; 128: 163-166 PubMed
11 Fell SC. Esophageal perforation. In: Pearson EG, Deslauriers J, Ginsberg RJ, Hiebert CA, Mc Kneally MF, Urschel HC Jr, editors. Esophageal surgery. New York: Churchill Livingstone, 1995: 495-515
12 Righini CA, Motto E, Ferretti G, Boubagra K, Soriano E, Reyt E. Diffuse cervical cellulites and descending necrotizing mediastinitis. Ann Otolaryngol Chir Cervicofac 2007; 124: 292-300

World Journal of Gastroenterology

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Saturday, March 01, 2008

Our experience using primary oral antibiotics in the management of orbital cellulitis in a tertiary referral centre

Our experience using primary oral antibiotics in the management of orbital cellulitis in a tertiary referral centre

Eye. 2008 Feb 29

Cannon PS, Keag DM, Radford R, Ataullah S, Leatherbarrow B.
1Oculoplastic and Orbit Department, Manchester Royal Eye Hospital, Oxford Road, Manchester, UK.

Correspondence: PS Cannon, Oculoplastic and Orbit Department, Manchester Royal Eye Hospital, Oxford Road, Manchester M13 WH, UK. Tel: +0044 161 276 5565; Fax: +0044 161 272 6618; E-mail:

Aims/PurposeOrbital cellulitis is conventionally managed by intravenous (i.v.) antibiotic therapy, followed by oral antibiotics once the infection shows signs of significant improvement. We report 4 years of experience using primary oral ciprofloxacin and clindamycin in cases of orbital cellulitis. Oral ciprofloxacin and clindamycin have a similar bioavailability to the i.v. preparations and provide an appropriate spectrum of antibiotic cover for the pathogens responsible for orbital cellulitis.MethodsA retrospective review was performed that identified all patients with orbital cellulitis and treated with primary oral antibiotic therapy admitted to the Manchester Royal Eye Hospital between March 2003 and March 2007. Age, stage of disease, surgical intervention, hospital duration, and complications were obtained. A comparison was made with patients admitted to our unit with orbital cellulitis and treated with primary i.v. antibiotics between March 2000 and March 2003.ResultsNineteen patients were included in the review for the period March 2003 to March 2007, which comprised of 7 children and 12 adults. Five patients required surgical intervention. All patients responded to the oral regimen, 18 patients had no change to their oral antibiotic therapy. Mean hospital stay was 4.4 days. There were no complications.DiscussionEmpirical oral ciprofloxacin and clindamycin combination may be as safe and effective as i.v. therapy in the management of orbital cellulitis. Oral treatment can offer the advantages of rapid delivery of the first antibiotic dose, fewer interruptions in treatment, and simplified delivery of medication particularly in children.

Eye advance online publication, 29 February 2008; doi:10.1038/eye.2008.44.


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