A 47-year-old man was referred to the emergency room in our hospital with swollen and painful right eye and face which had lasted 8 days. 3 days prior admission, the swelling seemed to be worsening and there was release of the pus.
The patient had a history of toothache since 2 years ago and bloody cough since 5 months ago. Further investigation did not revealed any history of trauma.
On admission, the patient presented with drowsiness, paleness, and fever. Visual acuity of the right eye was only light perception with limited eye movement in all directions. Examination revealed (Fig 1) non-axial proptosis, swelling of upper and lower eyelid with purulent discharge, chemosis, and purulent discharge on conjunctival bulbi and hazy cornea. There was fistula on right mandible to inner buccal which released pus.
Imaging modalities using CT scan (fig 2) revealed orbital sub-tissue swelling and sub-periosteal abscess on the upper lateral orbital wall. The laboratory test showed leukocytosis and elevated level erythrocyte sedimentation rate. A tentative diagnosis of orbital cellulitis with abscess formation was made. The patient was treated with intravenous ceftriaxone and metronidazole injection. The incision and drainage procedure was performed. The pus was collected, gram staining performed and culture done immediately.
We treated the patient conservatively in closed observation. On 3rd day of treatment, patient still had fever, cough, swelling on the right eye and face with active pus production. We ordered sputum smear microscopy test and chest X-rays. On the 5th day, the culture of the pus was confirmed using identification (ID) and antimicrobial susceptibility testing (AST), BD Phoenix (BD Diagnostic Systems, Sparks, MD) as extended spectrum beta-lactamases (ESBLs) producing Escherichia coli and Staphylococcus cohnii ssp urealyticum with susceptibility to ampicilin-sulbactam. Ziehl-Neelson staining test (fig 3) revealed acid fast bacillus with pulmonary inflammation highly pathognomonic of tuberculosis. Based on the culture result, the antibiotic regimen was modified through a consultation with pulmonary division and patient was scheduled to receive fixed doses combinations (FDC) for tuberculosis. We managed patient with intravenous ampicillin sulbactam, intravenous metronidazole, with irrigation and drainage of the abscess once a day.
On the 11th day, the swelling and abscess were resolved, followed by systemic condition improvement. The patient was discharged (fig 4) from the hospital on the 15th day in stable systemic condition with visual acuity hand movement on the right eye.