This article is more than 5 years old. Information may no longer be current.
Case seems complicated, but history is everything
Click Here to Manage Email Alerts
A 14-year-old male is transferred from a community hospital for evaluation and treatment of a right retro-orbital mass with headache, nausea, vomiting and dysconjugate gaze with diplopia. The history of his illness began about 1 week before this admission, with symptoms being fairly consistent. He has had no injury to the head or eye, and no fever recorded, but has felt warm at times. He was first seen at a different community hospital ED about 3 days into the illness and diagnosed with migraines and treated accordingly, but was also given a injection of an antibiotic (records not available, presumably ceftriaxone).
James H. Brien
However, his symptoms persisted, plus he developed diplopia. He sought care at a second (referring) hospital ED, where he had a head CT scan that showed something in the right retro-orbital space, prompting a full sepsis workup. All the lab tests, including the complete blood count (CBC), cerebrospinal fluid (CSF) and inflammatory markers, were normal. After cultures of blood and CSF were obtained, antimicrobial therapy was initiated with vancomycin and ceftriaxone, and he was transferred.
His medical history is that of a previously healthy adolescent male, whose immunizations are up to date. He had never had any significant infectious disease problem in the past, but did have a “staph” infection of his right knee, with several discrete abscesses that his primary provider drained in the office a couple of weeks before the onset of the current problem. Around this same time, his mother also had a couple of skin abscesses that were also drained. No cultures were taken of either. They were both empirically treated with trimethoprim-sulfamethoxazole orally with gradual resolution (Figure 1).
Figure 1. The patient had several abscesses on his right knee.
Source: Brien JH
Examination on admission revealed a normal-appearing 14-year-old male in some mild distress with headache and normal vital signs. The only abnormal findings included the healing lesions on his right knee, as shown, and the findings about his right eye; proptosis and restricted gaze as shown in Figures 2 and 3. An MRI of the orbits revealed the mass shown in Figure 4. Because of the lack of fever or abnormal lab tests, he was diagnosed by ophthalmology with an orbital pseudotumor and treated with IV steroids.
The only abnormal findings included proptosis and restricted gaze as shown in Figures 2 and 3.fermentum.
An MRI of the orbits revealed the mass shown in Figure 4. The patient was re-imaged with another MRI (Figure 5).
After some improvement in his symptoms, he was discharged 3 days later on oral steroids and oral clindamycin ("just in case"). However, 9 days later, his pain returned and he was re-imaged with another MRI (Figure 5), which was read this time as an abscess. His CBC on this admission showed a white blood cell count of 20,000 cells/mcL with 67% granulocytes, and he was taken to surgery for drainage, revealing pus.
What’s Your Diagnosis?
A. Group A streptococcus (GAS)
B. Staphylococcus aureus
C. Haemophilus influenzae type b
D. Pneumococcus
This turned out to be a retro-orbital abscess (B) caused by S. aureus (MRSA), and a good example of the folly in taking comfort in giving inappropriate antimicrobial therapy. Although the MRSA was sensitive to clindamycin, I know of no one who would recommend oral therapy for an orbital abscess; certainly not early on. So, one should not use such therapy as insurance, “just in case.” While orbital pseudotumor is a real entity, consisting of an inflammatory granulomatous mass, of unclear etiology, it is rare in children, and there were good clues to suspect a bacterial etiology, with the history of preceding skin abscesses in the patient and his mother. As has been true since the beginning of modern medicine, the patient history is the key to diagnosis, and this sort of history is very common for S. aureus; much more so than the other choices, and sometimes bacteremia may accompany such soft tissue infections, resulting in the “seeding” of other sites. In retrospect, this is clearly what happened in this patient. The atypical course may have been in part due to the spotty antimicrobial treatment the patient had been given, starting with the first admission, and complicated by the pre-existing skin abscesses treated with TMP-SMX. By the second admission, the problem was clear.
The problem of previous treatment with empiric antimicrobial therapy without knowing the cause was seen in a previous case that involved the partial treatment of a ventriculoperitoneal shunt tract infection (Figure 6). The patient had an injury site infection due to GAS, resulting in progressive, massive cellulitis and sepsis (Figure 7).
I addressed this problem — of previous treatment with empiric antimicrobial therapy without knowing the cause — in a case I presented for this column that involved the partial treatment of a ventriculoperitoneal shunt tract infection in February 2013 (Figure 6). That case also spanned more than one admission, as a direct result of partial, empiric treatment for an uncertain diagnosis. Hopefully, with enforcement of more antimicrobial stewardship in hospitals, we will see less use of antibiotics for “just in case” reasons. Also, it might have helped to have obtained a culture in the outpatient setting when the knee abscesses were drained.
Even if you believe that all soft tissue infections are due to S. aureus (as I have been told by other providers on several occasions), you never know when sensitivities might be important. And, if the abscess happens to be caused by GAS (Streptococcus pyogenes), the sulfa will likely not work, allowing the infection to progress virtually unimpaired, as demonstrated in a case in the March 2008 issue of this column. That patient had an injury site infection due to GAS, empirically treated with TMP-SMX, resulting in progressive, massive cellulitis and sepsis (Figure 7). Culture is still one of the cheapest tests we can do considering the benefit of knowing what’s going on when things go bad. And remember, not all soft tissue infections are caused by S. aureus.
Columnist Comments
I would like to draw your attention to Dr. William T. Gerson’s column, “Everyday Pediatrics,” in the February issue of IDC. In his brilliant description of the cost to professional education and, ultimately, patient care associated with medicine moving into the future, he reflects back on some important historic analogies. Our evolving electronic records systems strive to save us time and decrease mistakes with pre-worded, diagnosis-specific templates and “smart texts.” However, in my opinion, this often happens at significant cost to the substantive quality of notes; our primary way of communicating a specific patient’s care over time. Despite extensive clinic data that is automatically “populated” (I love that term) onto the note, accurate, useful information is often missing or buried in a sea of useless text; or even worse, revealing conflicting information because a box was either checked or not checked to properly fit the assessment. For example, a patient may have the throat appearance on the physical exam shown to be “normal,” but the assessment at the end of the note is “exudative tonsillitis.” Which is it?
Also, from the patient’s perspective, I have observed the following: watching the doctor constantly looking at the computer screen instead of the patient, as he or she spends most of the visit clicking on the keyboard, with very little time to actually spend on the exam or even looking the patient in the eye. However, on the upside, there’s bound to be fewer errors made in entering orders for testing and prescriptions/medications, as they are now usually done by the very doctor wanting them, instead of a clerk.
The problem of previous treatment with empiric antimicrobial therapy without knowing the cause was seen in a previous case that involved the partial treatment of a ventriculoperitoneal shunt tract infection (Figure 6). The patient had an injury site infection due to GAS, resulting in progressive, massive cellulitis and sepsis (Figure 7).
But, back to the point — from a medical education standpoint, I don’t know if there is a direct causal relationship or not, but it seems more than coincidental that since the logarithmic pace of the spread of this style of hospital and outpatient visit documentation, that somewhere along the way, teachers and students in our profession seem to have less time for each other. Medical education, in the tradition that has stood the test-of-time since Hippocrates held court under a tree in Kos, Greece, seems to be disappearing, and I don’t like it. I don’t like it as a patient, and I don’t like it as a teaching physician. I think the only ones who might like it are administrators and lawyers who can more easily “mine” for data (another favorite term) to audit our productivity. But at what cost? Lastly, I don’t seem to be saving any time, but rather, I’m doing the job previously done by support personnel who are now looking for work.
I believe that it is important to know where you have been to better understand where you may be going. So, as the practice of medicine moves further into the rapid-paced electronic future, which is unstoppable, an occasional review of our history might help keep us grounded to what’s important: patient care and education of our colleagues and students. In that way, perhaps we can hold on to some of the time-honored principles of practice and teaching, by occasionally turning around and looking back. There really are lessons still to learn, from our mentors and their mentors and so on; including the ancient legends of medicine.
Therefore, during the next few months, I would like to experiment with a brief series of short (one paragraph), historic reviews of great physicians, with some emphasis on pediatrics. I would like to invite reader participation from anyone interested — just email me. Perhaps we can begin next month with the great Persian physician Muhammad ibn Zakariya Razi (854 CE – 925 CE), the father of pediatrics.
Lastly, if you have an interesting case with a good picture and would like to have it considered for presentation at the 27th Annual IDC New York Symposium this November, just send it along to me, and we can take a look. I usually show one or two reader-donated cases at the meeting, followed by placing them in this column. Just let me know, and please keep in touch.
James H. Brien, DO, is vice chair for education in the department of pediatrics at McLane Children’s Hospital at Scott & White/Texas A & M College of Medicine in Temple, Texas. He is also a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.