|Year : 2015 | Volume
| Issue : 2 | Page : 128-131
Neonatal orbital abscess
Pratik Y Gogri1, Somen L Misra1, Neeta S Misra1, Hitesh V Gidwani2, Akshay J Bhandari1
1 Department of Ophthalmology, Pravara Institute of Medical Sciences, Loni, Maharashtra, India
2 Department of Internal Medicine, UPMC Mercy, Pennsylvania, Pittsburgh, USA
|Date of Web Publication||24-Jun-2015|
Dr. Pratik Y Gogri
Department of Ophthalmology, Rural Medical College and Pravara Institute of Medical Sciences, Loni - 413 736, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Orbital abscess generally occurs in older children but it can rarely affect infants and neonates too. We report a case of community acquired methicillin resistant staphylococcus aureus (CA-MRSA) neonatal orbital abscess in a 12-day-old term female neonate with no significant past medical history or risk factor for developing the infection. The case highlights the importance of consideration of CA-MRSA as a causative agent of neonatal orbital cellulitis even in a neonate without any obvious predisposing condition. Prompt initiation of appropriate medical therapy against MRSA and surgical drainage of the abscess prevents life threatening complications of orbital cellulitis which more often tend to be fatal in neonates.
Keywords: Methicillin resistant staphylococcus aureus, neonate, orbital cellulitis
|How to cite this article:|
Gogri PY, Misra SL, Misra NS, Gidwani HV, Bhandari AJ. Neonatal orbital abscess. Oman J Ophthalmol 2015;8:128-31
| Introduction|| |
Orbital cellulitis and abscess formation occur either from contiguous spread of infection from paranasal sinuses, eyelids and teeth or arises from exogenous sources like trauma or surgery. It may also develop from an endogenous source during systemic illness and spread to the orbital tissues through hematogenous route especially during septicemia. It is more common in adolescents than in adults.  Orbital cellulitis in childhood is at least twice as common among males as females.  It can cause life-threatening intracranial complications like meningitis, cavernous sinus thrombosis and epidural or subdural abscess formation.
Neonatal orbital abscess is very rare. To the best of our knowledge, just 16 cases of neonatal orbital abscess are reported in the literature till date.  It is caused by ethmoid sinusitis, dacryocystitis, and tooth bud abscess. The organisms implicated in the causation of neonatal orbital abscess include staphylococcus aureus commonly and sometimes streptococcus and very rarely aspergillus. We report a rare case of perinatal vertically acquired MRSA orbital abscess treated with linezolid and surgical drainage.
| Case Report|| |
A 12-day-old girl developed persistent fever along with rapidly increasing swelling and redness in the right eyelids since 2 days. On admission, the patient's temperature was 100.4°F, heart rate was 156 beats/min with no evidence of lymphadenopathy. On physical examination, the baby was lethargic, irritable and was not feeding well. The baby had an uneventful full term normal vaginal delivery with birth weight of 3 kg and no significant past medical history.
Ocular examination of the right eye revealed massive swelling, marked erythema and increased temperature of the upper and lower eyelids [Figure 1]a. There was proptosis of 5 mm. Conjunctiva showed congestion and grade three chemosis along with frank serous discharge. There was gross restriction of extraocular muscle movements in all gazes. The pupil was reactive to light without afferent pupillary defect. The rest of the anterior segment examination and fundus examination were within normal limits. Intraocular pressure was 15 mm of Hg. Left eye was within normal limits.
|Figure 1: (a) Lid edema and conjunctival chemosis of the right eye in a 12-days-old neonate at presentation (b) Increased lid swelling and proptosis after 3 days|
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On investigations, white blood cell count was increased to 23,200 cells/mm 3 with neutrophil predominance of 73% along with 15% lymphocytes, ten percent monocytes and two percent eosinophils. Erythrocyte sedimentation rate (ESR) was 86 mm/h. Blood, cerebrospinal fluid (CSF) and urine cultures were sterile. CSF examination was within normal limits.
A provisional diagnosis of orbital cellulitis was made. Empirical therapy with intravenous ceftazidime and amikacin were started. In spite of treatment, lid swelling and proptosis (12 mm) were increasing [Figure 1]b. Even the fever continued to rise being 101.1°F on the third day. There was further restriction of extraocular muscle movements in all gazes. Magnetic resonance imaging (MRI) of the orbit was suggestive of right orbital cellulitis with abscess formation involving the retrobulbar region of the right eye in postero-inferior quadrant of right orbital cavity extending to upper and lower antero-lateral quadrant with moderate degree of supero-lateral proptosis of right eye [Figure 2]. MRI brain and paranasal sinuses revealed no pathology.
|Figure 2: MRI images showing marked proptosis, pre-septal and post-septal inflammatory signs along with a well-defined extraconal heterogenous mass with walling off features suggestive of orbital abscess|
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As there was no response to systemic antibiotics and the swelling along with proptosis was increasing, surgical drainage of the abscess was performed via external approach through anterior orbitotomy under general anesthesia. Around 12 ml of thick yellowish pus was drained and sent for culture and sensitivity. All loculi of the abscess cavity were broken. The wall of the abscess cavity was excised and sent for histopathological examination. Flat silicon drains were placed. Culture of pus demonstrated methicillin resistant Staphylococcus aureus (MRSA) sensitive to vancomycin, linezolid, sparfloxacin, rifampin, and gentamicin.
Postoperatively, the patient received intravenous linezolid to which she responded very well with steady decrease in proptosis, swelling and fever over the next 7 days [Figure 3]a. Silicon drains were removed after 3 days. WBC count reduced to 12,300 cells/mm 3 and ESR to 22 mm/h with subsidence of temperature to normal after 5 days. The baby had eyelid retraction post-operatively which resolved spontaneously after 3 weeks [Figure 3]b. Eyelid edema subsided fully after 3 weeks of treatment with full and free movement of eyeball in all directions of gaze.
|Figure 3: (a) Gradual subsidence of lid edema and proptosis post-operatively (b) Appearance of lid retraction and it spontaneous resolution|
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| Discussion|| |
Orbital cellulitis is an uncommon serious life threatening infection in newborns. , It is an infrequent but serious complication of sinusitis in children. Neonatal orbital abscess is extremely rare.  It commonly occurs as a result of contiguous spread from surrounding periorbital structures as the tissue planes in neonates are less of a barrier to spread of infection as compared to children and adults.  Ethmoidal sinusitis is the most common cause of orbital cellulitis (more than 90% cases), especially in neonates who have not yet formed their frontal sinuses. 
There was absence of any of the predisposing risk factors for contiguous or hematogenous spread of infection like ethmoiditis, septic tooth bud, dacryocystitis or septicemia in our patient and also no maternal risk factor. She also lacked any risk factors for MRSA soft tissue infections, including chronic illness, chronic antibiotic usage, previous hospitalization, exposure to chronically ill individuals or hospital workers, and daycare.  The infection in this neonate may have most likely occurred subsequent to vertical transmission of MRSA from mother during vaginal delivery. Invasive disease following vertical transmission of CA-MRSA in neonates, though rarely, is known to occur. 
The incidence of community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA) infections has constantly been rising in the recent past most probably due to the emergence of new more virulent and transmissible strains.  Very few cases of CA-MRSA periocular infections in infantile patients have been reported and even more rarely in neonates. The most recent being a report of two cases of infantile CA-MRSA orbital cellulitis by Kobayashi et al., and a neonatal case by Tsironi et al. , Another case of perinatal CA-MRSA dacryocystitis and periorbital cellulitis in a 12-day-old previously healthy neonate have recently been reported by Rutar T. In this patient, vertical transmission of MRSA may have occurred during vaginal delivery or subsequent close contact, including breast feeding. 
Al-Salem et al., recently highlighted eyelid retraction as a sign of neonatal orbital abscess and its subsequent spontaneous resolution following successful treatment as was seen in our case.  The eyelid retraction became apparent in our case on sixth day post-operatively after decrease in lid edema subsequent to treatment response. There was spontaneous subsidence of lid retraction in our case too.
Neonatal orbital abscess is rarely encountered but when it does occur, it can be quite dangerous. Complications, especially the intracranial ones, tend to be more fatal in neonates. Prompt diagnosis and early intervention are required to ensure a favorable outcome. Appropriate antimicrobial agent against staphylococcus aureus is essential in treating neonatal orbital abscess along with surgical drainage when required. The cause in our case was most probably through vertical transmission of CA-MRSA from the mother which subsequently caused invasive cellulitis and abscess formation. This etiology is quite rare. Our case is unique for the use of linezolid for treating neonatal orbital abscess along with surgical drainage of the abscess. This case suggests that clinicians should be aware that neonates, even without any risk factors, are susceptible to orbital cellulitis caused by CA-MRSA. Prompt, early diagnosis and treatment with linezolid and surgical drainage is an effective treatment strategy against neonatal orbital abscess.
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[Figure 1], [Figure 2], [Figure 3]