Healthy toddler with infection in right lower eyelid

What’s your diagnosis?

A previously healthy, 32-month-old male is admitted to the hospital with an infection involving his right eye.

James H. Brien, DO

Five days earlier, his mother noted the presence of a small bump on his right lower eyelid, as well as some associated redness of the overlying skin and conjunctiva. She called her primary clinic and was told it was probably a stye and was instructed to try warm compresses and come in if not better soon.

Figure 1. A 32-month-old boy with lesions on his right eye. Image: James H. Brien, DO

Over the next 2 days, the erythema and swelling worsened, and he was therefore taken to his clinic the next day (day 3), where he was diagnosed with mild preseptal cellulitis and started treatment with oral clindamycin. By the next day, his eyelids were swollen shut with mild discomfort and a yellowish discharge, with new lesions on both eyelids, and older lesions having scabs as shown in Figure 1. He was then referred to ophthalmology, who opted for admission to the hospital. Upon admission, the above findings were confirmed on exam, as well as numerous small bumps and fluid-filled lesions scattered on the forehead, face and near the chin as shown in Figures 2 to 4.

Figure 2. A 32-month-old boy with lesions on his face. Image: James H. Brien, DO

Figure 3.  A 32-month-old boy with bumps on his chin area. Image: James H. Brien, DO

Figure 4. A closeup of lesions on a 32-month-old boy’s forehead. Image: James H. Brien, DO

The child’s past medical history, including mother’s pregnancy and the neonatal period, were documented to be unremarkable, and his immunizations were up to date. There had been no known injury to the face, and there were no other sick members of the family. There had been no recent travel or animal contact.

Upon admission, samples of the lesions were sent to the microbiology lab and nucleic acid amplification testing (NAAT) lab, and treatment began with IV clindamycin, ceftriaxone and acyclovir.

What’s Your Diagnosis (final treatment)?

A. Acyclovir alone

B. Ceftriaxone alone

C. Clindamycin alone

D. Continue clindamycin and ceftriaxone

Answer and discussion

The clues in the case showing numerous vesicles should have made it possible to strongly suspect herpes simplex virus (HSV) as the cause. The proof came from the labs, with negative bacterial cultures and a positive PCR for herpes simplex type 1 (HSV-1). Therefore, the answer would be to continue IV acyclovir alone. While being treated, he would need a thorough exam of his eye by an ophthalmologist to rule out herpes keratitis. In this case, the eye exam showed only mild inflammation of the conjunctiva with no HSV keratitis. By the time the lab results came back on day 3, significant improvement on IV acyclovir was noted, and his therapy was changed to oral acyclovir. He was discharged home to complete a 5- to 7-day course, which resulted in a good outcome.

The patient in this case was seen about 10 years ago. Today, we could use oral valacyclovir with its significantly increased blood levels. If one looks closely at the patient, it appears that all the lesions were on the right side of the midline, from the forehead on down, raising the question of shingles (varicella-zoster virus) rather than HSV. However, it would be extremely unlikely that the PCR test would give a false-positive result unless it was somehow mixed up. A couple of possible “lookalikes” with eyelids swollen closed with copious discharge might be gonococcal, as shown in Figure 5, or chlamydia ophthalmia as shown in Figure 6, in neonates, but not likely in older children.

Figure 5.  An infant with gonococcal ophthalmia. Image: Courtesy of JW Bass collection

Figure 6. An infant with chlamydia ophthalmia. Image: Courtesy of JW Bass collection

The choice of clindamycin alone might be a reasonable choice for preseptal cellulitis, especially if there has been an injury near the eye, as shown in Figure 7, as the vast majority are caused by Staphylococcus aureus, followed by group A Streptococcus. However, changes should always be based on culture and sensitivity results when possible.

Figure 7. A child struck by a toy with preseptal cellulitis. Image: James H. Brien, DO

The choice of continuing clindamycin and ceftriaxone might be the best answer if the child had orbital (postseptal) cellulitis, as shown in Figures 8 and 9. Today, one may consider ceftaroline for single drug coverage in orbital cellulitis. If surgical drainage is performed, then culture results can dictate further therapy; however, smaller orbital abscesses may be successfully treated without surgery.

Figure 8. A child with diffuse erythema about the left eye, with dysconjugate gaze. Image: James H. Brien, DO

Figure 9. A CT scan of the orbit showing impingement of the media rectus muscle for an orbital abscess. Image: James H. Brien, DO

Columnist comments

I wish you all a Happy and Healthy New Year. As always, if you have an interesting case with a picture that you think might be good to show in this column, just email me a brief description and a picture at jhbrien@aol.com. Also, let me know if you have any critical comments. I can take it.