Recurrent Orbital "Cellulitis"
A 4-year-old girl presented to her pediatrician with preseptal cellulites. It was supported by a computed tomography (CT) scan of the orbits (Figure 1), and she was treated with intramuscular injections of ceftriaxone and oral cefuroxime.
(Enlarge Image)
Figure 1.
CT orbits without contrast. Right preseptal fat stranding and ethmoid sinus disease.
Three days later, she was evaluated in the emergency room due to the onset of proptosis and fever. She was diagnosed with orbital cellulitis, admitted to the hospital, and treated with intravenous ceftriaxone. A CT scan and magnetic resonance imaging (MRI) of the orbits revealed a 2.5 cm by 7 mm "fluid filled phlegmon in the right lateral orbit with medial displacement of the lateral rectus" (Figure 2). Blood cultures were negative. The patient improved on the antibiotic therapy. After home health nursing was arranged, she was discharged from the hospital 6 days later on intravenous ceftriaxone.
(Enlarge Image)
Figure 2.
CT orbits without contrast. Right lateral wall mass causing medial displacement of the lateral rectus.
Two weeks later, she presented with recurrent proptosis and fever and was readmitted to the hospital. Infectious disease consultation recommended reinitiation of intravenous ceftriaxone. Repeat MRI showed no change in her orbital findings but revealed meningeal enhancement anterior to the right middle cranial fossa (Figure 3 and Figure 4). Blood cultures were again negative. The patient improved and was discharged 5 days after admission.
(Enlarge Image)
Figure 3.
MRI orbits, T2 weighted. Right lateral wall mass, previously noticed on CT, with fluid-filled pockets.
(Enlarge Image)
Figure 4.
MRI orbits, T1 weighted. Right lateral wall mass causing medial displacement of the lateral rectus.
Upon discharge, the patient was referred to a local otolaryngologist. After reviewing the films, he felt that the findings were inconsistent with an abscess. She was referred to our institution for a second opinion.
We saw the patient approximately 4 weeks after the onset of her symptoms. The child's mother reported that her symptoms had mostly resolved; however, she did note mild ptosis of the right upper eyelid, which she felt was present prior to the onset of symptoms. Examination revealed visual acuity of 20/20 in each eye. Pupillary and motility examinations were normal. There was evidence of approximately 2 mm of right eyelid ptosis and no proptosis. The external exam was otherwise normal and fundus exam was unremarkable.
Based upon the findings described and the neuroimaging studies, this patient most likely has:
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<p>Pseudo-rheumatoid nodule</p><br/><b>Discussion</b><br/><br/><p/>
Clinical Presentation
A 4-year-old girl presented to her pediatrician with preseptal cellulites. It was supported by a computed tomography (CT) scan of the orbits (Figure 1), and she was treated with intramuscular injections of ceftriaxone and oral cefuroxime.
(Enlarge Image)
Figure 1.
CT orbits without contrast. Right preseptal fat stranding and ethmoid sinus disease.
Three days later, she was evaluated in the emergency room due to the onset of proptosis and fever. She was diagnosed with orbital cellulitis, admitted to the hospital, and treated with intravenous ceftriaxone. A CT scan and magnetic resonance imaging (MRI) of the orbits revealed a 2.5 cm by 7 mm "fluid filled phlegmon in the right lateral orbit with medial displacement of the lateral rectus" (Figure 2). Blood cultures were negative. The patient improved on the antibiotic therapy. After home health nursing was arranged, she was discharged from the hospital 6 days later on intravenous ceftriaxone.
(Enlarge Image)
Figure 2.
CT orbits without contrast. Right lateral wall mass causing medial displacement of the lateral rectus.
Two weeks later, she presented with recurrent proptosis and fever and was readmitted to the hospital. Infectious disease consultation recommended reinitiation of intravenous ceftriaxone. Repeat MRI showed no change in her orbital findings but revealed meningeal enhancement anterior to the right middle cranial fossa (Figure 3 and Figure 4). Blood cultures were again negative. The patient improved and was discharged 5 days after admission.
(Enlarge Image)
Figure 3.
MRI orbits, T2 weighted. Right lateral wall mass, previously noticed on CT, with fluid-filled pockets.
(Enlarge Image)
Figure 4.
MRI orbits, T1 weighted. Right lateral wall mass causing medial displacement of the lateral rectus.
Upon discharge, the patient was referred to a local otolaryngologist. After reviewing the films, he felt that the findings were inconsistent with an abscess. She was referred to our institution for a second opinion.
We saw the patient approximately 4 weeks after the onset of her symptoms. The child's mother reported that her symptoms had mostly resolved; however, she did note mild ptosis of the right upper eyelid, which she felt was present prior to the onset of symptoms. Examination revealed visual acuity of 20/20 in each eye. Pupillary and motility examinations were normal. There was evidence of approximately 2 mm of right eyelid ptosis and no proptosis. The external exam was otherwise normal and fundus exam was unremarkable.
Based upon the findings described and the neuroimaging studies, this patient most likely has:
Rhabdomyosarcoma
Hemangioma/lymphangioma
Orbital cellulitis with abscess
Pseudo-rheumatoid nodule
View the correct answer.
<p>Pseudo-rheumatoid nodule</p><br/><b>Discussion</b><br/><br/><p/>
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