A 2-year-old male with 2-day history of erythema, swelling of apex of nose

Issue: May 2018

ByJames H. Brien, DO

A 2-year-old male presents with a 2-day history of progressive erythema and painful swelling of the apex of his nose. Initially, he complained of only pain with the erythema, but by the second day, he had some epistaxis, raising his parent’s concern. He was then taken to his primary provider, who immediately sent him to the children’s hospital ED for evaluation.

Figures 1 and 2: A healthy-appearing male with a painful, erythematous and swollen apex of his nose, with some old blood in and about the right nostril.

His past medical history was that of a healthy 2-year-old male, with no significant illnesses or injuries. There is no history of injury or foreign body in his nose. His immunizations were up to date.

Examination revealed normal vital signs and a healthy-appearing male with a painful, erythematous and swollen apex of his nose, with some old blood in and about the right nostril (Figures 1 and 2). The patient was seen by the otolaryngology consultant, who admitted him to the hospital and took him to the operating room for incision and drainage of an abscess involving the lateral wall of the right nostril. A Gram stain of the pus was positive for Gram-positive cocci and Gram-negative rods, and a culture is pending.

What severe complication is associated with this infection?

A. Bacterial meningitis

B. Cavernous sinus thrombosis

C. Necrosis of the nose with spontaneous detachment

D. A and B

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Case Discussion

The answer is D, both A and B, bacterial meningitis and cavernous sinus thrombosis. Mid-face infections run the risk of septic emboli traveling via the anterior facial and/or ophthalmic veins to the cavernous sinus, where a septic thrombus can form, placing pressure on nearby structures and spreading to the meninges. Nasal infections tend to lead the list of causes, followed by infections involving the orbits. These anatomic areas of the face fall into what is often called “the triangle of danger” (Figure 3), as illustrated by my grandson, Harrison, when he was about 3 years of age. (In Harrison’s case, the triangle of danger probably runs from head to foot.)

Therapy includes aggressive medical and surgical management. The usual pathogen is Staphylococcus aureus, followed by group A strep (Streptococcus pyogenes), often mixed with other organisms, including Gram-negative rods and upper respiratory tract anaerobes. Therefore, initial empiric antimicrobial therapy is usually a combination of vancomycin plus ceftriaxone, or a similar combination.

This patient had MRSA that was sensitive to clindamycin (without inducible resistance). Therefore, after surgical drainage and 3 days of IV therapy, with clear improvement back to his normal baseline, and no concerns for progression, he was sent home on oral clindamycin for 10 more days, with normal follow-up. However, if there is any question about progression with either a cavernous sinus thrombosis or meningitis, a vascular CT or MRI along with an LP should be performed, with appropriate surgery and adjustments in therapy.

Figure 3: Anatomic areas of the face fall into what is often called “the triangle of danger.”

The only infection I know of that would make the nose fall off would be long-standing, untreated tertiary syphilis, and even then, it does not really “fall off,” but rather is replaced by gummatous changes. This is almost unheard of nowadays.

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Figure 4. Patient with a similar infection of the nose that required drainage and showed MRSA.

Figure 7. Postsurgical drainage.

Figure 8. Patient after treatment.

Figure 9. Patient with severe nose cellulitis and third nerve impairment.

Figure 10. Patient with severe nose cellulitis and third nerve impairment.

Source: Lewis Hutchinson, MD.

Figure 11. Septic thrombosis.

Figure 12. Recovery from medical and surgical methods to treat nose cellulitis and third nerve impairment, with a septic thrombus.

Figure 13. Severe ethmoid sinusitis with S. aureus septicemia and CST.

Figure 14. Septic thrombosis.

Source: Lewis Hutchinson, MD.

Figure 15a and b. Recovery after surgery and prolonged IV antistaphylococcal antimicrobial therapy to treat severe ethmoid sinusitis with S. aureus septicemia and CST.

Over the years, we have seen many cases of midface infections, including two that progressed to CST due to ethmoid sinusitis, as well as infections of the nose with near life-threatening results.

In the November 2003 issue of Infectious Diseases in Children, I featured a patient (Figures 4 – 7) with a similar infection of the nose that required drainage and also showed MRSA. This patient was treated the same as the patient presented in this issue, with good results (Figure 8). However, a case of severe nose cellulitis and third nerve impairment (Figures 9 and 10) with a septic thrombus (Figure 11), was seen. The patient was treated with heroic medical and surgical methods (courtesy of Lewis Hutchinson, MD), with a good outcome (Figure 12).

Lastly, a patient with severe ethmoid sinusitis with S. aureus septicemia and CST (Figures 13 and 14) was seen, requiring surgery and prolonged IV antistaphylococcal antimicrobial therapy. The patient recovered (Figure 15 A and B).

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 also is 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.