A Case of Progressive Orbital Cellulitis in an Immunocompetent Patient - Abstract

A 74 year-old woman presented 2/7/2015 with left orbital swelling/discomfort. Imaging revealed paranasal sinus and orbital soft tissue abnormalities suggestive of inflammatory/infectious disease. She received intravenous vancomycin/meropenam but worsened. Medical history was notable for paroxysmal atrial fibrillation, arthritis, cervical intraepithelial neoplasia (grade 3). Visual evaluation at the time revealed a normal right eye and a left eye with NLP vision and IOP of 78mmHg. She underwent an emergent left lateral canthotomy bedside on 2/7/15, and ENT performed an anstrotomy, ethmoidectomy, sphenoid sinustomy, and frontal sinusotomy on 2/08/2015, with negative bacterial and fungal cultures. She also had left carious molars and necrosis of the mandibular bone, which was debrided; cultures showed light growth of both non-candida yeast and candida and fluconazole was started. The following week, she had a seizure and MRI showed cavernous sinus thrombosis which was treated with anticoagulation. Despite intravenous antibiotics and fluconazole, she worsened. Repeat MRI showed enchancing soft tissue throughout the left orbit and paranasal sinuses, numerous lytic skull lesions and pachymeningeal enchancement. CT showed intermediate pulmonary nodules, mild mediastinal/hilar lymphadenopathy, and subpleural reticulations in both lungs. Orbital biopsy revealed granulomatous inflammation without organisms; scalp biopsy showed many CD68+ histiocytes. Neuro-ophthalmological examination on 4/16/2015 was notable for persistent left orbital pain, numbness over V1 and V2 distributions, left orbital soft tissue swelling, and complete ptosis of the left upper eyelid. The right eye had 20/20 acuity; the left eye was phthisical with NLP vision. On the left there was 2+ diffuse conjunctival injection, corneal edema and haze, firm globe to palpation; iris neovascularization and near complete angle closure; there was no view behind the iris. Humphrey automated visual field testing of the right eye was reliable and showed a mean deviation score of -6.05dB, with generalized depression of sensitivity. Dilated stereoscopic funduscopy on the right was essentially normal