Cellulitis

INTRODUCTION Preseptal cellulitis is defined as inflammation and infection confined to the eyelids and periorbital structures anterior to the orbital septum. The orbital structures posterior to the septum are not involved, but may be secondarily inflamed. In children, the most common cause of preseptal cellulitis is underlying sinusitis. Preseptal cellulitis in children under age 5 was often associated with bacteremia, septicemia, and meningitis caused by Haemophilus influenzae, however, this cause of preseptal and orbital cellulitis has virtually been eliminated by the introduction of the HIB vaccine. Currently, most cases of preseptal and orbital cellulitis in children are due to gram-positive cocci. In teenagers and adults preseptal cellulitis usually arises from a superficial source such as traumatic inoculation, or a chalazion. The site of the infected focus is often difficult to find because the eyelid tissues become markedly swollen.

CLINICAL PRESENTATION The initial skin lesion is often a small, erythematous focus, suggesting an early furuncle, but instead of localizing, it rapidly spreads through the adjacent subcutaneous tissues after 5 to 10 days. Eyelid edema, erythema, and inflammation may be severe. Unless the infection spreads to the post-septal orbit, the globe is uninvolved; pupillary reaction, visual acuity, and ocular motility are not disturbed; pain on eye movement and chemosis are absent. Complications can result in lagophthalmos, ectropion, and lid necrosis.

Lagophthalmos Ectropion

HISTOPATHOLOGY Cellulitis, or diffuse inflammation of the connective tissue of the skin or deeper soft tissues, may be acute or chronic. Acute cellulitis is characterized histopathologically by an infiltrate of neutrophils throughout the dermis and/or subcutaneous tissue. There may be subepi-dermal edema and vascular ectasia. In chronic cellulitis the inflammatory infiltrate consists mostly of lymphocytes and macrophages and is accompanied by fibrosis and angiogenesis.

Erysipelas Microscopy

DIFFERENTIAL DIAGNOSIS The differential diagnosis includes orbital cellulitis, erysipelas, Mucormycosis, and ruptured dermoid or epidermoid cyst.

TREATMENT Initial antibiotic selection is based on the history, clinical findings, and initial laboratory studies. With positive culture, prompt sensitivity studies are indicated so that the antibiotic selection can be revised, if necessary. Staphylococcus aureus is the most common pathogen in patients with preseptal cellulitis from trauma. The infection usually responds quickly to penicllinase-resistant penicillin. Imaging studies should be performed to rule out underlying sinusitis if no direct inoculation site is identified. If the patient does not respond quickly to oral antibiotics or if orbital involvement becomes evident, prompt hospital admission, CT scanning and intravenous antibiotics are usually indicated. Surgical drainage may be necessary if the preseptal cellulitis progresses to a localized abscess. Incision and drainage can usually be performed directly over the abscess. The orbital septum should not be opened to avoid contaminating the orbital soft tissue. Affected children should be treated in consultation with a pediatrician, and hospi-talization and intravenous antibiotics may be indicated.

REFERENCES

Baker C. Group B streptococcal cellulitis-adenitis in infants. Am J Dis Child 1982; 136:631.

Casady DR, Zobal-Ratner JL, Meyer DR. Eyelid abscess as a presenting sign of occult sinusitis. Ophthal Plast Reconstr Surg 2005; 21:368-370.

Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum. Ophthalmology 1998; 105:1902-1905.

Feingold D. Gangrenous and crepitant cellulitis. J Am Acad Dermatol 1982; 6:289-299.

Harris GJ. Subperiosteal abscess of the orbit: age as a factor in the bacteriology and response to treatment. Ophthalmology 1994; 101:585-595.

Harris GJ. Subperiosteal abscess of the orbit: computed topography and the clinical course. Ophthal Plast Reconstruct Surg. 1996; 12:1-8.

Parunovic A. Proteus mirabilis causing necrotic inflammation of the eyelid. Am J Ophthalmol 1973; 76:543-544. Rao VA, Hans R, Mehra AK. Pre-septal cellulitis—varied clinical presentations. Indian J Ophthalmol 1996; 44:225-227.

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