Conjunctivitis and Orbital Inflammation in a 24-Year-Old Man
REPORT OF A CASE
A 24-year-old male laboratory technician visited the emergency department with marked swelling of his right ear and left eye. A diagnosis of orbital cellulitis was made in the emergency department. An immediate computed tomographic scan demonstrated preseptal soft-tissue swelling, and a magnetic resonance image 2 days later showed a worsening preseptal inflammatory process with intraorbital extension (Figure 1A). On initial examination, visual acuity was 20/15 OD and 20/40 OS, auricular and periorbital edema was pronounced, and tender lymphadenopathy was noted. No eyelid vesicles or pustules were observed. Marked chemosis and a purulent discharge were present, but the cornea was clear. Motility examination revealed full ductions in the right eye with severe limitation in all fields in the left eye (Figure 2). A 1 x 1-cm weeping brown skin lesion surrounded by induration, erythema, and crusting was found on the posterior pinna (Figure 1B). Treatment with intravenous vancomycin hydrochloride, clindamycin phosphate, and piperacillin sodium with tazobactam sodium was started. A conjunctival pseudomembrane obscuring the cornea was removed on the second hospital day and sent for pathologic analysis (Figure 1C), and a symblepharon discovered medially in the left eye was lysed.
What is your diagnosis?
Figure 1. Images of the patient. A, Postgadodiamide spin-echo T1-weighted axial magnetic resonance image with fat saturation showing pronounced thickening and enhancement of the left preseptal soft tissue, left conjunctival thickening, inflammation extending into the postseptal extraconal fat around the left medial rectus, and left-sided retrobulbar fat stranding and enhancement. R indicates right; P, posterior. B, Ear lesion at the 1-week follow-up. C, Epithelial cells in a fibrin matrix with abundant eosinophilic cytoplasm (hematoxylin-eosin, original magnification x400).
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Figure 2. Periorbital edema and severe restriction of extraocular movements in the 9 cardinal positions of gaze.
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Please e-mail your diagnosis to ophthquiz{at}ama-assn.org. You must include your full name, mailing address, and institutional affiliation in the initial e-mail to be eligible to enter the quiz. The first correct respondent will be recognized in the print journal and on our Web site and will also be able to choose one of the following books published by AMA Press: Clinical Eye Atlas, Clinical Retina, or Users' Guides to the Medical Literature. Because of the volume of responses we are able to respond to the first person with the correct answer only.
For a complete presentation of this case and an in-depth discussion of the entity, please see next month's edition of Archives of Ophthalmology.
Congratulations to the winner of our October quiz, Anna Gabrielian, MD, Chief Resident, Section of Ophthalmology and Visual Science, Department of Surgery, University of Chicago, Chicago, Illinois.
The correct answer to our October challenge was leukemia.
For a complete discussion of this case, see the Letters: Research Letters section in the November Archives (Bhatnagar A, Wilkinson LB, Tyagi AK, Willshaw HE. Subinternal limiting membrane hemorrhage with perimacular fold in leukemia. Arch Ophthalmol. 2009;127[11]:1548-1550).
Next month's quiz will be available on December 14, 2009, at 3 pm Central time.