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17-month-old male presents with fever, right periorbital swelling
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A previously healthy 17-month-old male, whose past medical history is positive only for being significantly behind in his immunizations, presented to a local ER with fever and right periorbital swelling.
The onset was 3 days earlier, when his mother noted an erythematous pustule in the same location. There was no known history of injury or insect bite. His temperature at that time was 100.2°F, and his mother thought he was coming down with a cold. Over the next 2 days, he developed more pain, and he was noted to feel warm. The area of erythema had increased significantly, and the pustule spontaneously drained some yellowish material.
Source: James H. Brien, DO
Because of this worsening course, he was taken to the ER, where his temperature was noted to be 102.9°F with the findings noted above. A maxillofacial CT scan (Figure 1) revealed preseptal soft tissue swelling without orbital extension or abscess noted. A blood culture was obtained, and he was given a dose of IV ceftriaxone before being transferred to the children’s hospital.
Examination on arrival was that of a febrile (103°F), 17-month-old male in mild distress with pain, who was active and alert.The only pertinent findings was the area of erythema and swelling over a large area just inferior to his right eye, with a spot of dried blood on the lateral edge of erythema where the lesion had spontaneously drained (Figures 2 and 3). There was a lighter area of erythema that developed around the more intense area that seemed to include the upper lid as well. The exam also discovered a blistering lesion with surrounding erythema on his left thumb (Figure 4), of which his mother was apparently unaware. The blister appeared to contain a layer of blood. The rest of his exam was normal.
Abnormal lab tests included an elevated white blood cell count of 16.0 and C-reactive protein of 59. Empiric therapy with vancomycin and ceftriaxone was begun pending culture results. Because of the development of fluctuance, the ophthalmology consultant incised and drained the underlying abscess in the infraorbital area, and the thumb blister was also drained during the same period of sedation, with both samples revealing gram-positive cocci in clusters.
What’s your diagnosis?
A. Haemophilus influenzae type b
B. Streptococcus pyogenes
C. Herpes simplex
D. Staphylococcus aureus
Case Discussion
Given the information above, the most likely cause for this infection is Staphylococcus aureus (D), for the following reasons: (1) Herpes simplex can certainly produce facial and finger lesions, and they can occur simultaneously (unlikely). However, it is not likely to cause widespread surrounding erythema, and more likely to produce a cluster of vesicles. (2) S. pyogenes (group A strep) can be a cause of facial cellulitis with abscess formation and is the classic cause of blistering distal dactylitis. If not for the time factor, this would be my second choice. We expect group A strep to progress rapidly (hours, not days) compared with an S. aureus infection (3) In the pre-Hib vaccine years, H. influenzae type b was a common cause of facial cellulitis, both pre-septal and buccal (Figure 5). However, this infection has almost disappeared in our country because of widespread immunizations and herd immunity, which can even benefit the unimmunized.
Under the eyes of an experienced microbiologist, a properly stained specimen can predict the culture results to follow. And as one might expect with gram-positive cocci in clusters, S. aureus (MRSA) grew from both specimens in this case. With this information, the ceftriaxone was discontinued. After 5 days of IV vancomycin, with significant improvement, and because the MRSA was sensitive to clindamycin, the patient went home on oral clindamycin to complete a 2-week course of therapy with a good outcome.
- For more information:
- James H. Brien, DO, is an adjunct professor of pediatrics with the section of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, 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.
Comment: It is likely that the patient was bacteremic and “seeded” his thumb. There was no other explanation for this to coincidentally occur at the same time as the facial cellulitis, which likely started with a common break in the skin, such as an insect bite that was scratched open. Although he had a high fever, he was never clinically septic or toxic.
Over the years, I have seen several cases of S. aureus blisters that appeared to have a thick overlying dome of skin. In addition to the one shown in this case, some other examples are shown in Figures 6 to 8, which were from an adolescent with a spontaneous S. aureus blister on the knee; a S. aureus blister on the plantar surface of the left foot from another child, before and after drainage and debridement (Figures 9 to 11), and finally, Figure 12, a S. aureus blister on the palm of the left hand from a child, as seen in our 2011 column.
As most of you probably already know, these areas of the body (palms, soles, knees and elbows) have thicker skin because of the different, more “work-related” function, so when a subcutaneous infection with S. aureus occurs, the blister, or superficial abscess will have a thicker dome of overlying skin. This would seem to be different than bullous impetigo, which results from common S. aureus impetigo because of an epidermolytic toxin-producing strain, resulting in a thin blister with clear fluid (Figure 13).
