Girl presents with scab on her nose, swelling
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A 10-year-old female presented to her primary care provider’s office with some redness and painful swelling of the area about her nose and mid-face.
The history of this problem began when she developed a “pimple” on the bridge of her nose 4 days earlier. After picking at the pimple for a couple of days, she noted the onset of the erythema and painful swelling, which progressively worsened. She had no fever or other new symptoms and otherwise felt well. Her provider sent her to the ED for further management of this mid-facial cellulitis.
Examination on admission reveals normal vital signs and a normal-appearing 10-year-old female with a scab on the bridge of the nose and significant swelling with erythema of the nose and surrounding soft tissues, from the infraorbital areas bilaterally, down to the maxillary areas, as shown in Figure 1. A CT scan of the sinuses reveals a collection of fluid adjacent to the nasal septum (Figure 2).
What serious complication may this patient encounter?
A. Meningitis
B. Epistaxis
C. Cavernous sinus thrombosis
D. Both A and C
Answer and discussion:
The answer is D: both bacterial meningitis and cavernous sinus (CS) thrombosis are possible complications of mid-facial cellulitis. Some of you may recognize that I showed a different case of mid-facial cellulitis with abscess 3 years ago and back in 2002 as well. The reason for showing these cases is that they are potentially dangerous, even fatal, and continue to occur, with the need for reinforcement learning.
Infections about the mid-facial areas (mostly nasal) run the greatest risk of septic emboli traveling through the valveless anterior facial vein in a retrograde fashion to the ophthalmic vein and the CS. An infection in the CS can be life-threatening, with potential for significant morbidity, as several important structures, such as cranial nerves as well as the internal carotid artery, traverse the CS. The cavernous system is valveless, allowing infected blood to travel to the dural venous sinuses via emissary veins, resulting in meningitis. It should be noted that a report by Zhang and colleagues in 2010 disputed that these veins are truly valveless, based on dissections of cadaver veins. This revealed that some (but not all) of these veins were found to have valves by stereomicroscopy.
An example of severe CS thrombosis with meningitis is seen in Figure 3, which began as a pustule on the nasal bridge. That patient survived only with heroic ICU management. Remember, the triangle of danger extends from the top corners of the mouth to the area between the eyes (ethmoid sinus area), as shown in Figure 4.
Lastly, epistaxis (choice B) may be seen but is not a significant complication of this infection.
The patient in this case had surgical drainage (Figure 5), and the culture grew methicillin-sensitive Staphylococcus aureus. She received IV therapy until she saw significant improvement and went home on high-dose cefalexin to complete a 2-week course of treatment. She had no clinical evidence of meningitis.
Columnist comments
Over the years, as noted earlier, I have now shown three similar but different cases of mid-face infections. The questions are always the same: “What are the complications?” When I am consulted on a patient in the hospital with a mid-face infection, I have frequently found that the temptation is to underestimate the life-threatening potential of an infection in this location. At first glance, it may look like a simple pustule on, in or about the nose area, with a little erythema surrounding it. It is unknown how often a “pimple” may arise in this location and be squeezed to drain the contents with uncomplicated resolution because those patients would not seek medical care. However, as we all know, that practice may lead to a localized cellulitis or abscess, which may worsen. If the patient happens to come in early in the course of the infection, it may be difficult to imagine this becoming a life-threatening problem. If that is the case, my advice would be to drain and culture any collection of pus, no matter how small, and see the patient back within the next 24 to 48 hours. Whether you use empiric antimicrobial therapy in the meantime is a judgement call, but my threshold would be fairly low. If so, I would cover for S. aureus and Streptococcus pyogenes with an oral anti-staph penicillin or first-generation cephalosporin with or without clindamycin. That alone may abort the progression of the infection. But, if the patient’s infection has worsened on follow-up, then at least you would have a culture that can help guide your IV therapy in the hospital. The point is, don’t take these mid-face infections lightly.
Lastly, summer is here, and all its hazards await: injuries, skin infections, bites, heat exhaustion, swimming pool injuries and enterovirus infections. Be on the lookout for children presenting with fever and headache, especially in a biphasic pattern; that is, a minor initial phase followed in 3 to 7 days by a more severe phase. Typically, adolescents will complain of the worst headache they have ever had with enteroviral aseptic meningitis. Lumbar puncture (LP) is often therapeutic as well as diagnostic. The enterovirus can usually be detected in the cerebrospinal fluid (CSF) by PCR. The cellular parameters of the CSF may show an initial predominance of polymorphonuclear leukocytes but soon (usually 24 to 36 hours) revert to a lymphocyte predominance. In the days before sophisticated viral identification was available, patients who were sick enough to treat empirically oftentimes had to have a second LP in order to demonstrate this cellular shift before discontinuing antibiotics with confidence. This was especially true before the widespread use of the conjugated vaccines for Haemophilus influenzae type b and Streptococcus pneumoniae, which caused most of the cases of bacterial meningitis in children up until the late 1980s.
This ends the history lesson for this month. Please keep in touch and let me know your recommendations.
Reference:
Zhang J, Stringer MD. Clin Exp Ophthalmol. 2010;doi:10.1111/j.1442-9071.2010.02325.x.
For more information:
Brien is a member of the Infectious Diseases in Children and Infectious Disease News Editorial Boards, and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.