H.P.I.-M.Z 9/9-11a.m.
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Transcript of H.P.I.-M.Z 9/9-11a.m.
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H.P.I.-M.Z 9/9-11a.m.H.P.I.-M.Z 9/9-11a.m.
40y/o male with swelling,redness,and drainage from the left eye for last few days.
E.O.M.’s intact.”No suspicion of deep infection at this time”.
Treatment Keflex 500mg Q 6hr P.O. and check with Ophthalmology in the a.m.
(1gram of Rocephin i.m.)
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M.Z. 9/10 2amM.Z. 9/10 2am
2a.m. 9/10 M..Z. referred from Sauk City E.R. with severe headache,periorbital pain, proptosis,lateral globe displacement,and restricted adduction. (-) A.P.D. V.A. 20/80
Cat scan:Ethmoid/Maxillary sinusitis and 25 m.m.x11m.m. subperiosteal abscess
P.M.H. 1996 Mandibular fracture & Ethmoid (medial wall) fracture(Supramid implant). Dental work 4 days ago
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Subperiosteal AbcessSubperiosteal Abcess
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Hospital CourseHospital Course
Dx.Orbital Cellulitis with Subperiostal abscess. Team approach P.C.P.,Infectious Disease, and
Oculoplastic surgeon Tx. Ceftriaxone 2gm q 12hr.iv, Clindamycin 900
mg q 8 hr,Vancomycin 1 gm,q12 hr. started immediately
9/11 (L) orbitotomy with removal of implant and abscess drainage. Culture alpha Strep &coag.neg Staph.
Discharged 9/15 on oral antibiotics, symptoms resolved vision normal.
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MRSAMRSA
Community acquired
– Increased potential for tissue invasion
– Found in young athletes and inmates
– Progresses despite appropriate treatment
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Case ReviewCase Review
Day 1: 44 yr old male squeezed a pustule in his nose
Day 3: fever and chills developed, treated with TMP/SMX DS and Rifampin
Day 4: Admitted for eyelid swelling, WBC 24,000.Rx- Vancomycin + Ceftriaxone + Metronidazole
Day 5: Massive proptosis, ophthalmoplegia,
bilateral vision loss
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FindingsFindings
• Pupils unreactive, central retinal arteries and veins occluded
• Congestion of optic discs
• Orbital and brain MRI –bilateral orbital cellulitis, pansinusitis, cavernous sinus enlargement
•MR venogram confirmed cavernous sinus thrombosis
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Hospital courseHospital course
Paranasal sinuses drained endoscopically
Day 13: iv heparin and methylprednisolone
In retrospect, may have benefited from orbital decompression sooner
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Preseptal cellulitis RX
Dicloxacillin
Augmentin
Macrolides
Quinolones
3rd gen. Cephalosporin
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Orbital Cellulitis
Ceftriaxone & Metronidazole Vancomycin
Ampicillin/Sulbactam
Ticarcillin/Clavulanic acid & Vancomycin
Imipenen/Meropenem & Vancomycin
Fluoroquinolone & Clindamycin
Aztreonam
Amphotericin
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Team WorkEYE
ENT
ID
NEUROSURGERY
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•Team Approach
•History very important in determining the most likely organism. Culture may bedifficult.
•Frequent re-evaluations are necessary.
•Imaging studies are very helpful in diagnosis and monitoring treatment.
•Serious problem can result in death.
HEADS UP
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Differential Dx. ProptosisDifferential Dx. Proptosis
Infection Orbital cellulitis Cavernous sinus thrombosis
Neoplastic Metastatic Ca Lymphoma Rhabdomyosarcoma Retinoblastoma Leukemia Letterer-Siwe disease
Endocrine
Orbital Inflammation Pseudotumor Orbital myositis Wegener’ granulo-
matosis
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ANATOMYANATOMY
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Haemophilus InfluenzaeHaemophilus Influenzae