Pediatrics in Review
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(Pediatrics in Review. 2005;26:337-340.)
© 2005 American Academy of Pediatrics

Visual Diagnosis

Visual Diagnosis

A 9-year-old Girl Who Has Fever, Headache, and Right Eye Pain


Linda S. Nield, MD*
Deepak Kamat, MD, PhD{dagger}
 * Associate Professor of Pediatrics, West Virginia University, Morgantown, WV
{dagger} Professor of Pediatrics; Director, Institute of Medical Education, Vice Chair of Education, Children’s Hospital of Michigan, Detroit, Mich

The first 300 words of the full text of this article appear below.


   Presentation
 
A 9-year-old girl presents to the emergency department with a 24-hour history of fever to 103.8°F (39.9°C); headache; worsening right eye pain; and right-sided red, swollen eyelids. A day earlier, she was found to have preseptal (periorbital) cellulitis at another urgent care facility, was treated with amoxicillin/clavulanate, and was discharged from the hospital. Despite three doses of the oral antibiotic, her condition has deteriorated.

The child has had multiple episodes of sinusitis in the last several years, her most recent bout occurring 3 weeks ago. Her past medical history is otherwise unremarkable. She is at the 50th percentile for height and weight for her age. Family history is noncontributory. There is no history of allergies, immunodeficiencies, or cystic fibrosis.

On physical examination, the child appears ill, yet is alert and oriented. Her vital signs are: temperature, 103.8°F (39.9°C); pulse, 110 beats/min; and respiratory rate, 16 breaths/min. Her right upper and lower eyelids and surrounding facial tissue are red and swollen (Fig. 1). Vision, funduscopic, and extraocular muscle examinations cannot be completed because of her severe eye pain and eyelid swelling. Nasal mucosa is erythematous and swollen and partially obscured by dried, yellow discharge. The child has good dentition, normal tympanic membranes, and no meningismus. Findings on the rest of the physical examination are unremarkable.


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  		Figure 1. Right eyelid erythema and edema. Note that the erythema does not extend beyond the orbital ridge.

Laboratory evaluation reveals a total white blood cell count of 10x103/mcL (10x109/L), with 71% polymorphonuclear cells, no bands, 18% lymphocytes, 10% monocytes, and 1% eosinophils. A blood culture and head and orbital contrast-enhanced computed tomography (CT) scan are obtained.


   Diagnosis:Postseptal Cellulitis With Subperiosteal Abscess
 
Orbital CT reveals right periorbital soft-tissue swelling, inflammatory changes in the medial aspect of the right orbit with obvious displacement of the globe, and . . . [Full Text of this Article]






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