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A 3-year-old boy with severe infection
3¾-year-old boy was admitted to the Children’s Hospital at Scott and White via the emergency room (ER) for management of a severe infection of the left side of his face and possible sepsis.
The history of this illness began 24 hours earlier when he was struck in the area of his left eyebrow by a door knob when the door was suddenly opened with the patient on the other side (I think this happened to me once). He was taken to a local emergency room where six sutures were used to repair the laceration. However, the next morning, he woke up with fever and marked painful swelling of the area about the injury. He was taken back to the ER for evaluation and was treated with oral trimethoprim/sulfamethoxazole (TMP/SMX). However, his condition worsened through the day and he came to the ER, where his vital signs revealed a fever of 104.2° F, with tachycardia (pulse = 180) and tachypnea (respirations = 48).
Pediatric Infectious Disease, Scott and White's Children's Health Center and Associate Professor of Pediatrics,
Texas A&M University, College of Medicine, Temple, Texas.
e-mail: jhbrien@aol.com
His past medical history was remarkable for having a sore throat with a positive strep screen a couple of weeks earlier that was treated with amoxicillin. His immunizations are up to date.
His family history is normal and he has a family dog, which occasionally licks his face.
Examination on admission revealed the patient to be alert and oriented, with marked swelling of the left side of his face as shown in figures 1 – 3. No other associated injuries were noted, and the rest of his examination was normal.
A computed tomogram (CT) of his face revealed the swelling of the soft tissue and some fluid (Figure 4 & 5). Lab tests included an elevated white blood cell count at 17,900. Blood cultures were obtained and he was given a saline bolus and a dose of intravenous ceftriaxone and vancomycin in the ER before sending him to the pediatric intensive care unit, where the lesion was drained and cultured. The pus never grew an organism.
What’s Your Diagnosis (most likely cause)?
- Methicillin-resistant Staphylococcus aureus (MRSA)
- Capnocytophaga canimorsus
- Group A streptococcus (Streptococcus pyogenes)
- Pseudomonas aeruginosa
Answer
This is a little tricky, and you must consider the hints in the question to arrive at what I think is the answer.
Since the cultures never grew an organism, the answer will simply be my opinion, which is group A strep (GAS - choice C). There are three reasons why I feel that GAS is the cause:
1. The recent history of streptococcal pharyngitis, therefore he was known to at least be recently colonized. Streptococcal pharyngitis in this age group is very uncommon, but not unheard of, and again, it is only important to know that he was recently colonized.
2. The speed of progression is typical for GAS soft tissue infections. It is not unusual to see GAS cellulitis progress to this degree in 24 hours, as opposed to Staphylococcus aureus, which seems to spread a bit slower.
And 3, the lack of positive cultures. It is common for exudates caused by GAS to be “sterile” when cultured if even one dose of an effective antibiotic has been given. I have seen this occur time and again, occurring in everything from soft tissue abscesses to pleural empyema (Figure 6, a case of culture positive GAS empyema, which was culture negative after one dose of cefuoxime). Lastly, one needs to remember TMP/SMX is not effective against group A strep.
MRSA is certainly the organism MOST LIKELY to cause soft tissue cellulitis and abscess overall. But the onset from injury to abscess is usually slower, often taking a couple of days or more to get to this point. Secondly, the exudate is usually still culture-positive regardless of a few doses of antibiotics, as shown in figure 7, a similar case of MRSA cellulitis with abscess that occurred secondary to a minor injury several days earlier. When taken for incision and drainage (Figure 8), the Gram stain and culture were still positive even though the patient had received several doses of intravenous vancomycin prior to the procedure.
Capnocytophaga canimorsus can cause cellulitis, but is fairly rare and usually caused by the bite of a dog. It can cause a rapidly progressive infection with life-threatening sepsis in asplenic or other immunodeficient patients. And lastly, Pseudomonas aeruginosa was just thrown in. This would be a very unusual cause of cellulitis in the normal patient.
Our patient presented did well with drainage and antibiotics (Figure 9). Vancomycin and ceftriaxone was continued for the first few days, and then changed to clindamycin for the duration of 10 days of treatment. Again, cultures remained negative.
Meeting will be missed
For the first time since the first meeting in 1981, the National Pediatric Infectious Disease Seminar (NPIDS) is not being held.
For 27 years, the NPIDS always took place the week after Easter. It was the brilliant idea of Drs. John D. Nelson and George H. McCracken of The University of Texas Southwestern Medical School in Dallas.
I attended all but two of these annual educational events. The first one that I missed was when I was a first-year infectious disease fellow with Jim Bass in Hawaii, and simply was not allowed off due to requirements of the program. The next time was when I was deployed to Saudi Arabia and Iraq during the first Gulf War (commanders were a little funny about us leaving during that time). The first NPIDS was held in Las Vegas and the first lecture was given by George McCracken on new cephalosporins. At that time, Rocephin was referred to as RO 13-9914. Antibiotic development was exploding with activity, and most of our time as ID people was spent just keeping up with what was new, and George went on for many more years giving an annual antibiotic update.
The next lecture was given by John Nelson, who spoke on otitis media, the most common reason antibiotics are prescribed in children. While John and George were always the main attractions, they spared no expense in bringing in the top people in their specific area of pediatric infectious diseases, who also happened to be very good speakers. Saul Krugman ended that first NPIDS three days later with a lecture on hepatitis that stands today as the best I’ve ever heard.
The syllabus consisted of type-written handouts that were packed with information, not just the copies of the slides being shown by the speakers, because PowerPoint had not yet been invented. Even before PowerPoint, all speakers had to comply with very strict criteria when it came to slide format, which was known to be easiest for the audience to see from anywhere in the room. But speakers did not mind and as time went by, the best speakers would do what ever it took to be invited to be on the NPIDS program.
The NPIDS thrived for more than 25 years, becoming not only a top quality annual CME event, but also a reunion of old friends who we could always count on seeing once a year. Among the highlights in my professional life were the times I was a speaker at the NPIDS, and will miss it greatly. But more than that, I will miss the camaraderie of the many loyal attendees who my wife and I considered like family, such as Ramasamy Mahadevan, MD, of Lancaster, California, who attended all 27 NPIDS.
Through the years, the NPIDS helped move many pediatricians to specialize in infectious diseases, and educated many more in the things you really need to know for every day practice. So, thanks go out to John Nelson and George McCracken for providing more than 700 hours of quality CME and 27 years of great memories.
What’s Your Diagnosis? is a monthly case study featured in Infectious Diseases in Children, with treatment information and discussion to follow.