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Arch Ophthalmol. 2004;122:1233-1234.

An idiopathic muscle abscess is a rare condition that should be considered in the differential diagnosis of painful limitations of eye movements and double vision in children.

We herein present the case of an idiopathic muscle abscess in an 11-year-old girl. Myositis was initially suspected, but the magnetic resonance imaging (MRI) scan showed typical signs of an abscess. Antibiotic therapy led to a rapid and complete improvement of all symptoms. To our knowledge, this is the first report of an idiopathic isolated abscess in an extraocular muscle in a child.

Report of a Case
An otherwise healthy 11-year-old girl was intially seen because of a 4-week history of periorbital and upper eyelid edema (Figure 1A), pain during eye movements of the left eye, and double vision. Visual acuity was 20/20 OD and 20/40 OS. A maximum of 9° of hypotropia was found on the left side in upgaze and abduction. Binocular visual field was shifted 10° below primary position. No signs of intraocular or extraocular inflammation were seen. Afferent and efferent pupil reactions were normal. Further examination disclosed a subjective desaturation of red color on the left side. No proptosis could be found on results of exophthalmometry.

View larger version (34K): [in this window] [in a new window] Figure 1. Patient photographs before (A) and after (B) treatment.

Ocular sonography (standardized echography, A- and B-scan) showed a thickening of the left superior rectus. Orbital MRI scan showed an abscess (diameter, 8 mm) with central cavitation and a rim of contrast enhancement of about 3 mm surrounded by a diffuse swelling of the left superior rectus muscle (Figure 2A and B).

View larger version (77K): [in this window] [in a new window] Figure 2. Oblique sagittal (A) and axial (B) T1-weighted contrast-enhanced spin-echo magnetic resonance imaging (MRI) scans. Diffuse swelling of the left superior rectus muscle is seen surrounding an abscess (diameter, 8 mm), with central cavitation and rim of contrast enhancement of about 3 mm (arrows). Oblique sagittal (C) and axial (D) MRI scans after therapy show discrete residual swelling of the left superior rectus muscle.

The measured serological variables (including adenovirus, human herpesvirus 6, herpes simplex virus, varicella-zoster virus, enterovirus, Borrelia burgdorferi, Epstein-Barr virus, measles virus, human immunodeficiency virus, syphilis, and cysticercosis) and cerebrospinal fluid variables (including sediment, glucose and protein levels, and serological findings for B burgdorferi and Russian spring-summer encephalitis) were within reference range.

Immediately after the first visit, high-dose intravenous antibiotic therapy was introduced (combination of amoxicillin sodium and potassium clavulanate, 8.8 g/d for 10 days). No amelioration of symptoms could be observed after 2 days, so metronidazole (1.35 g/d for 5 days) and ceftriaxone disodium (2 g/d for 19 days) were added. This led to a rapid and complete improvement of all symptoms (visual acuity of 20/20 OU, free motility in all directions in both eyes without double vision, and no inflammatory signs, including eyelid edema ([Figure 1 B]). An MRI control scan, obtained 2 weeks after initiation of therapy, showed only a discrete residual swelling of the affected muscle (Figure 2 C and D).

Comment
Main differential diagnoses in children are other inflammations and infections (eg, diffuse orbital pseudotumor, orbital cellulitis),¹ structural lesions (eg, dermoid cyst),² vascular neoplastic lesions (eg, capillary hemangioma, lymphangioma),³ lymphoproliferative diseases (eg, lymphocytic granuloma),⁴ neurogenic tumors (eg, neuroblastoma, plexiform neurofibroma),⁵ mesenchymal tumors (eg, rhabdomyosarcoma), and metastatic carcinoma.

Although the clinical features are frequently suggestive of myositis, they are nonspecific, and noninvasive investigations such as orbital ultrasonography and MRI scans are required for precise anatomical tissue localization and diagnosis.

The role of ocular muscle biopsy is probably limited to atypical cases, or those unresponsive to therapy, particularly to exclude neoplasia.

The authors have no relevant financial interest in this article.

AUTHOR INFORMATION

Timo Haufschild, MD; Peter Weber, MD; Ines Nuttli, MD; Burkhard Hecker, MD; Josef Flammer, MD; Hedwig J. Kaiser, MD

Correspondence: Dr Flammer, University Eye Clinic, Mittlere Strasse 91, PO Box, CH-4012 Basel, Switzerland (Josef.Flammer{at}uhbs.ch). Dr Haufschild may be contacted at THaufschild{at}uhbs.ch

REFERENCES
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