Boy’s punctured cheek swells with pain, erythema

What’s your diagnosis?

A healthy, 10-year-old boy seeks care for a sore left cheek.

James H. Brien, DO

The problem began 4 days earlier when he had an accident while driving a four-wheel, all-terrain vehicle, resulting in an injury to his left cheek, which may have been punctured by one of his upper teeth. There was some initial bleeding and pain, but he did not seek care at that time. The area was cleaned with soap and water. However, 2 days later, he noticed the gradual increase in pain and swelling of the area, with some erythema. Today, the injury appears as shown in Figure 1. He has not seen any discharge.

Figure 1. Injury showing that the tooth may have gone through the cheek due to a four-wheeler accident. Image: James H. Brien, DO

The patient has no underlying health problems, and his immunizations are documented to be up to date, including a tetanus immunization within the last 5 years.

Your examination reveals normal vital signs and the injury to the left cheek, as well as a similar injury to the left oral buccal mucosa, with intact, healthy-looking teeth.

What’s your diagnosis (most likely organism)?

Eikenella corrodens

Haemophilus influenzae type b

Staphylococcus aureus

Streptococcus pyogenes

Answer and discussion:

While all the choices can be part of the oral microbiome, and under certain conditions, they can be the cause of an orofacial infection, the best answer in this case is Staphylococcus aureus. It is not clear whether a through-and-through injury by a tooth occurred, or if an external injury caused the lesion on the patient’s left cheek, while an overlying tooth injured the buccal mucosa. In either case, S. aureus leads the list of likely organisms based on statistics and the speed of onset of the symptoms. Soft tissue infections due to group A strep (GAS or Streptococcus pyogenes) tend to progress rapidly after implantation of the organism. Figure 2, which originally appeared in the May 2014 column, shows a 9-year-old child with a dog bite to the right infraorbital area and left cheek that occurred 1 day earlier. A more dramatic example of this feature of rapid progression in GAS infection can be seen in the March 2008 column, which showed a 4-year-old boy who injured his head with a laceration that required sutures. The next morning, he had a low-grade fever, erythema and some swelling, and was given trimethoprim/sulfamethoxazole (TMP/SMX), apparently thinking it was infected with S. aureus and not GAS, since TMP/SMX is ineffective against the latter. However, the boy returned 10 hours later in septic shock and massive swelling with erythema of his face (Figure 3) and some early blistering over the buccal area, requiring admission to the ICU, surgical drainage and IV antibiotics for 10 days with a good outcome (Figure 4). So, in less than 36 hours, the patient went from injury to the ICU with GAS sepsis. I might point out that a patient who returns to be seen the day after having stiches with a low-grade fever and some erythema about the injury should probably have had the sutures removed and left open, but that’s a judgement call that is easy to make later. And, in case you are wondering about the dog bite previously mentioned, yes — GAS can be found in the mouths of dogs (as well as the on the skin of the face). However, GAS is uncommonly found on the buccal mucosa, even in a raging case of streptococcal tonsillitis, making it less likely in the event of a tooth puncture wound through the cheek.

Figure 2. GAS infection due to dog bite to the right infraorbital area and left cheek of a 9-year-old. Image: James H. Brien, DO

Figure 3. Massive GAS infection the day after an injury requiring sutures. Image: James H. Brien, DO

Figure 4. The patient in Figure 3 after recovery. Image: James H. Brien, DO

Eikenella corrodens is a common, gram-negative, fastidious, facultative, anaerobic bacillus found in the mouth of humans and uncommonly in dogs and cats as well. It is most commonly seen in human bite infections and in “clinched fist” injuries from fights, causing cellulitis of the hand (Figure 5). E. corrodens can also be found in dog and cat bite infections (Figures 6 and 7). Another clue is that it may take a week or more after the injury to demonstrate clinical signs of infection.

Figure 5. A clinched fist injury infection. Image: James H. Brien, DO

Figure 6. Eikenella infection after a dog bite. Image: James H. Brien, DO

Figure 7. A closeup of Figure 6. Image: James H. Brien, DO

Lastly, Haemophilus influenzae type b (Hib) would rarely be found in the mouth (or anywhere else) of a 10-year-old child, especially if fully immunized. The only case of Hib meningitis I saw in the last 25 years of my practice career was in a 26-month-old toddler who missed the fourth dose of Hib immunization of the four-dose series. It was scary but mild, and he did well. It nonetheless demonstrates the need for the full series of the recommended product being used. The Hib immunization also speaks to the excellent herd-immunity effect of the conjugated Hib immunization. Most children aged older than 5 years are not colonized with Hib, and if disease occurs in a fully immunized patient, it would be reportable. My personal experience goes back to the era of “raging” Hib infections and the time after the introduction of the Hib polysaccharide immunization in 1985. It was immunologically unreliable in children aged younger than 2 years, but the subsequent development of the conjugated Hib immunization in 1987 had a dramatic effect, essentially halting this very dangerous childhood infectious disease agent. What does this have to do with the case presented? One of the common infections young children developed with Hib was buccal cellulitis, as shown in Figure 8. Additionally, it was found that buccal cellulitis in these babies and young children put them at a roughly 10% risk for having concomitant meningitis with Hib, even if asymptomatic. Therefore, all those young patients with buccal cellulitis needed a spinal tap to rule out meningitis, with or without clinical signs or symptoms, because it could be evolving, and knowing that would significantly impact the management. The word Haemophilus was derived from the Greek word meaning “blood lover,” and would go wherever the blood took it; blood (sepsis), brain, bones (and joints), buccal, breath (pneumonia and epiglottis), beating heart (pericardium), behind the eyes (orbital cellulitis) — virtually anywhere.

Figure 8. Haemophilus influenzae type b buccal cellulitis. Image: James H. Brien, DO

Columnist comments:

Regarding the empiric use of TMP/SMX for initial soft tissue infections, I had a well-meaning general surgeon argue with me that all soft tissue infections associated with injury are due to S. aureus and therefore do not need culturing, and that TPM/SMX is the drug of choice because it is effective and easy (twice a day). As noted earlier, the problem is that TMP/SMX is not active against GAS. Of course, I am rarely consulted on cases of S. aureus cellulitis with abscess formation due to injuries, but I am commonly consulted on the rest because they are usually more serious and the patient may be on the wrong antibiotic. The argument arose when a complicated soft tissue infection due to an injury was not cultured when the surgeon did the incision and drainage. Nonetheless, I failed to convince him, and the “beat goes on.”

Lastly, it is time to immunize your patients and yourselves. The new COVID-19 and influenza immunizations have been out for a while now. I strongly recommend both, especially if you treat sick patients. As usual, please let me know if you have a good case that you would like to see in this column.

References:

• Brien JH, Bass JW. J Pediatr. 1985;doi:10.1016/s0022-3476(85)80354-1.
• Talan DA, et al. N Engl J Med. 1999;doi:10.1056/NEJM199901143400202.