Atypical presentations of orbital cellulitis in an 11-year-old boy

Spontaneous acute-onset proptosis accompanied with inflammatory signs in children is commonly caused by orbital cellulitis/abscess; however, the clinician should always be alert to the possibility of other causes such as neoplastic: Orbital rhabdomyosarcoma (RMS), traumatic, and iatrogenic factors. This is a case report of an 11-year-old boy presenting with an acute-onset non-axial proptosis of the left eye without a history of trauma, sinus disease, or systemic infection. Our clinical differential diagnosis included orbital cellulitis and orbital RMS. However, the final diagnosis was orbital cellulitis with abscess. The purpose of the study was to report a case of “cold” orbital abscess that clinically mimics orbital RMS. An 11-year-old boy presented with a 2 weeks history of painless, rapid-onset non-axial proptosis in the left eye. It was associated with periorbital edema, and mild conjunctival hyperemia. There was no preceding or associated history of fever, trauma, upper respiratory tract infection, sinusitis, or immunosuppression. An initial clinical diagnosis of RMS, with orbital cellulitis as a differential diagnosis, was made delaying commencement of antibiotic therapy. Following the drainage of greenish tinged purulent matter growing Staphylococcus aureus on culture, the diagnosis of orbital cellulitis with abscess was made. A broad-spectrum antibiotics and subsequent adjunct anti-inflammatory therapy yielded excellent clinical resolution. The case demonstrates the pitfalls/challenges in differentiating orbital space occupying lesions manifesting with inflammatory features on the basis of clinical findings alone. This is particularly relevant in a busy triage ophthalmic clinic in a low resource environment without easy access to any form of orbital imaging. In addition, the case highlights that green tinged purulent matter can be found in infections from a myriad of organisms aside from the popularly known Pseudomonas aeruginosa.

Treatment of Suppurative Otitis Media in Paediatric Patients

Thirty-nine paediatric patients with suppurative otitis media were studied. General principles of treatment were followed and sodium cefazolin ( a new cephalosporin effective even on β- lactamase-producing organisms) was given intramuscularly at a dose of 25 mg/kg every 12 hours. Clinical effectiveness was excellent, since 100% of patients were cured by the 7th day of treatment at the latest and 80% within 48 hours. Drug levels in the blood and purulent matter from the middle ear were determined in five cases, and it was found that cefazolin concentrates 2.5 times more in this secretion than in the blood. The need for myringotomy in the early stages of the disease, as well as for daily aspiration of secretion, is stressed, as is the use of an antimicrobial agent resistant to the inhibiting effect of penicillinase and cephalosporinase since, in our environment, 41% of bacteria causing this pathology produce these enzymes.

Note on Spirochaetes in Castration Tumours of Pigs

In pigs in Western Australia it is of frequent occurrence to find at the seat of castration large oval fibrous tumours from the size of an hen's egg to that of a tennis ball. These have a thick fibrous wall with a cavity in the centre, which is frequently small in relation to the size of the mass. The walls of this cavity are brownish-yellow and degenerated and the contents usually sero-pus of a similar colour, though at times a large quantity of ordinary whitish purulent matter is found. In films made from this brownish-yellow pus and stained with weak carbol-fuchsin or Leishman's stain, varying numbers of spirochaetes mixed with minute cocci and bacilli and larger, occasionally spore-bearing, organisms will be found. These spirochaetes vary in length from 6 μ or less to 12 μ; their thickness varies from the most delicate tenuity to that of a tubercle bacillus; the spirals may be three or four and perfectly regular or, on the other hand, quite irregular, and acute bendings even at a right angle may be seen. Further, some of the large apparently bacillary organisms may show slight undulations suggesting that they are large forms of this spirochaete. Sections of the tumour show a fibrous stroma, becoming more cellular towards the centre where it passes into necrosed tissue swarming with organisms, amongst which, sometimes in masses, spirochaetes may be found. Where the still living cells abut on the necrosed area, a varying number of eosinophile cells are revealed by Leishman's stain.

XVI. Observations and experiments on pus

Chemical writers vary in their statements of the properties of pus; and they consider that a further investigation is requisite for the purposes of science. Physicians confess that, in numerous cases, they cannot form a satisfactory judgment of the nature of diseases, on account of not being able to determine what is, and what is not purulent matter; likewise probably, on account of the existence of different kinds, or varieties, at least, of this substance, afforded by different disorders. I beg leave, therefore, to submit to this learned Society, my own observations, experiments, and reasoning on this animal matter.