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Vongsachang H, Chiou CA, Azad AD, Lin LY, Yoon MK, Lefebvre DR, Stagner AM. Periorbital necrotizing sweet syndrome: A report of two cases mimicking necrotizing soft tissue infections. Am J Ophthalmol Case Rep 2024; 34:102033. [PMID: 38487334 PMCID: PMC10937104 DOI: 10.1016/j.ajoc.2024.102033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/08/2024] [Accepted: 02/20/2024] [Indexed: 03/17/2024] Open
Abstract
Purpose Two cases are described of necrotizing Sweet syndrome (nSS), a rare variant of acute febrile neutrophilic dermatosis that mimics necrotizing soft tissue infections. Observation A 74-year-old female with myelodysplastic syndrome (MDS) presented with isolated periorbital nSS that closely mimicked necrotizing fasciitis (NF); she displayed pathergy to debridement, was exquisitely responsive to corticosteroids, and underwent successful first-stage reconstruction of the eyelid with full-thickness skin grafting. A second 40-year-old female patient with relapsed acute myelogenous leukemia (AML) presented with multifocal nSS most prominently involving the eyelid. Positive herpes zoster virus (HSV) PCR and bacterial superinfection complicated the diagnosis. She improved with chemotherapy for AML and corticosteroid therapy. Conclusion nSS is rare and a high level of clinical suspicion as well as an understanding of its distinguishing features is necessary to avoid undue morbidity. Identification of pathergy, histopathology, microbiology, and clinical context are critical to avoid misdiagnosis of infection.
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Affiliation(s)
- Hursuong Vongsachang
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Carolina A. Chiou
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Amee D. Azad
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Lisa Y. Lin
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Michael K. Yoon
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Daniel R. Lefebvre
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Anna M. Stagner
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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Hojjatie SL, Radulovich N, Van Brummen A, Chambers C, Fu R, Mittenzwei R, Zhang MM. A case of necrotizing fasciitis of the orbit secondary to Aspergillus fumigatus and mixed flora. Orbit 2024:1-4. [PMID: 38796787 DOI: 10.1080/01676830.2024.2353235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024]
Abstract
A 79-year-old female presented to the emergency department for sudden-onset ocular pain, edema, and erythema around her left eye. She also had a left-sided migraine and frontal fullness for 2 weeks. She had attentive care for the diagnosis of orbital cellulitis and prompt recognition of necrotizing fasciitis. Wound cultures were positive for over 5 strains of bacteria in addition to Aspergillus. In a combined effort by our institution's Ophthalmology and Otolaryngology departments, the patient was successfully treated with debridement, porcine bladder matrix, antibiotics, and antifungals. The authors describe the first reported case of eyelid and periorbital necrotizing fasciitis, caused by mixed flora and Aspergillus fumigatus, that showed promising wound healing with the outlined treatment paradigm.
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Affiliation(s)
- Sara L Hojjatie
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
| | - Nicholas Radulovich
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
| | - Alexa Van Brummen
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
| | | | - Roxana Fu
- Department of Ophthalmology, University of Pittsburg, Pittsburg, Pennsylvania, USA
| | - Rhonda Mittenzwei
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Matthew M Zhang
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
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Wladis EJ, Bohnak CE, Law JJ, Adam AP, Rothschild MI, Pauze DR. Neutrophil-to-Lymphocyte Ratios Distinguish Idiopathic Orbital Inflammation From Orbital Infectious Disease. Ophthalmic Plast Reconstr Surg 2024; 40:178-180. [PMID: 37695130 DOI: 10.1097/iop.0000000000002519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
PURPOSE The neutrophil-to-lymphocyte ratio (NLR) is a relatively novel biomarker to distinguish between acute stresses. This study was performed to determine whether the NLR may discern infectious orbital maladies from idiopathic orbital inflammation (IOI). METHODS The NLR was calculated by a review of the initial blood draws of adult patients who presented to the emergency department at a single academic medical center. Statistical comparisons were performed to identify the significance of these results. RESULTS Ten patients with IOI, 12 patients with necrotizing fasciitis (NF), and 12 patients with orbital cellulitis (OC) presented to the emergency department. The groups were not statistically significantly different in terms of age or gender. The mean NLRs were 3.48 (standard deviation = 1.80), 13.5 (standard deviation = 14.5), and 8.15 (standard deviation = 6.56) for IOI, NF, and OC, respectively. Patients with IOI had statistically significantly lower NLRs than patients with NF ( p = 0.037) and OC ( p = 0.034). However, the NLRs of patients with OC were not statistically significantly different from those of patients with NF ( p = 0.27). CONCLUSIONS The NLR appears to distinguish IOI from infectious etiologies, but does not discern between variants of infection. These results should be juxtaposed against appropriate imaging and clinical evaluations, but elevated NLR values may heighten clinicians' concerns for an infectious process and encourage them to initiate appropriate management steps.
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Affiliation(s)
- Edward J Wladis
- Department of Ophthalmology, Lions Eye Institute, Albany Medical College, Albany, New York
- Department of Otolaryngology, Albany Medical College, Albany, New York
| | - Carisa E Bohnak
- Department of Ophthalmology, Lions Eye Institute, Albany Medical College, Albany, New York
| | - James J Law
- Department of Ophthalmology, Lions Eye Institute, Albany Medical College, Albany, New York
| | - Alejandro P Adam
- Department of Ophthalmology, Lions Eye Institute, Albany Medical College, Albany, New York
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, New York
| | - Michael I Rothschild
- Department of Ophthalmology, Lions Eye Institute, Albany Medical College, Albany, New York
| | - Denis R Pauze
- Department of Emergency Medicine, Albany Medical College, Albany, New York, U.S.A
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Wladis EJ, Tomlinson LA, Moorjani S, Rothschild MI. Serologic Evaluations in the Distinction Between Sinusitis-Related Orbital Cellulitis and Periorbital Necrotizing Fasciitis. Ophthalmic Plast Reconstr Surg 2023; 39:599-601. [PMID: 37338341 DOI: 10.1097/iop.0000000000002437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
PURPOSE While sinusitis-related orbital cellulitis (SROC) and periorbital necrotizing fasciitis (PNF) share similar clinical presentations, they are managed differently, making rapid recognition of the appropriate clinical entity critical to optimal outcomes. This study was performed to assess whether serologic testing might help clinicians to distinguish between SROC and PNF. METHODS A retrospective review analysis was used to compare initial complete blood counts and comprehensive metabolic panels among adult patients with SROC and PNF. Statistical evaluations were used to determine the significance of differences between the groups. RESULTS Thirteen patients with PNF and 14 patients with SROC were identified. The 2 groups were similar in age, gender, and likelihood of immunosuppression ( p > 0.05 for each metric). Mean leukocyte counts were 18.52 (standard deviation = 7.02) and 10.31 (standard deviation = 5.77) for PNF and SROC, respectively ( p = 0.0057). White blood cell levels were above normal limits for 12 patients with PNF (92.3%) and 7 patients with SROC (50%) ( p = 0.017). No other laboratory test was significantly different between the 2 groups. CONCLUSIONS While the majority of serologic testing was quite similar in patients with either SROC or PNF, leukocyte levels may represent an important clue to distinguish between the two diseases. Clinical evaluation remains the gold standard to make the proper diagnosis, but markedly elevated white blood cell counts should prompt clinicians to at least consider a diagnosis of PNF.
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Affiliation(s)
- Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Slingerlands, New York, U.S.A
- Department of Otolaryngology, Albany Medical College, Slingerlands, New York, U.S.A
| | - Lauren A Tomlinson
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Slingerlands, New York, U.S.A
| | - Smriti Moorjani
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Slingerlands, New York, U.S.A
| | - Michael I Rothschild
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Slingerlands, New York, U.S.A
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Rothschild MI, Pacheco RR, Wladis EJ. Predicting severity of periorbital necrotizing fasciitis. Orbit 2022; 42:228-232. [PMID: 35686501 DOI: 10.1080/01676830.2022.2087231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To determine whether severity of periorbital necrotizing fasciitis can be predicted based on premorbid patient characteristics. METHODS Records of 10 consecutive patients with periorbital necrotizing fasciitis presenting at a single center, treated by one attending ophthalmic plastic surgeon, were retrospectively reviewed. Demographic information and medical history were used to determine a Charlson Comorbidity Index (CCI) score for each patient. Other variables included presenting visual acuity, number of surgical debridements performed, infectious organism (if known), and visual acuity at last follow-up. Data were compared with Mann-Whitney U test to determine correlation between variables, using p-values as outcome measures. RESULTS Increased age at presentation correlated with worse presenting and final visual acuity, requiring more surgical debridements to control disease (each p < .0001). Worse initial visual acuity correlated with need for increased number of debridements (p = .002), but increased number of debridements did not correlate with final visual acuity (p = .101). CCI did not correlate with initial vision (p = .30), final vision (p = .72), or number of surgical debridements necessary (p = .99). Presenting visual acuity did not correlate with final visual acuity (p = .268). CONCLUSION Older patients have more severe cases of periorbital necrotizing fasciitis, as defined by increased number of surgeries required to control disease and worse visual outcomes. CCI did not correlate with severity of disease.
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Affiliation(s)
- Michael I Rothschild
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Lions Eye Institute, Albany Medical College, Albany, New York, USA
| | | | - Edward J Wladis
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Lions Eye Institute, Albany Medical College, Albany, New York, USA
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Wladis EJ. Periorbital Necrotizing Fasciitis. Surv Ophthalmol 2022; 67:1547-1552. [DOI: 10.1016/j.survophthal.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
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Yazıcı B, Sabur H, Toka F. Periocular Necrotizing Fasciitis Causing Posterior Orbitopathy and Vision Loss: How to Manage? Turk J Ophthalmol 2021; 51:181-183. [PMID: 34187154 PMCID: PMC8251672 DOI: 10.4274/tjo.galenos.2021.17364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Necrotizing fasciitis (NF) is a rare, rapidly progressive bacterial infection. Periorbital NF may spread from the eyelid into the posterior orbit. Extent of the infection is critical in planning surgical debridement. A diabetic 70-year-old man presented with a black wound and severe pain in the left periorbital area following a mild trauma. Clinical findings were consistent with NF involving the eyelids, temporal and malar regions. In addition, he had proptosis, diffuse ophthalmoplegia, and central retinal artery occlusion, suggesting deep orbital involvement. Computed tomography showed soft tissue abnormalities in the anterior orbit. The patient was successfully treated with subcutaneous debridement, antibiotherapy, and metabolic support. Periorbital NF may be complicated with posterior orbital cellulitis-like symptoms and retinal vascular occlusions, possibly because of remote vascular thrombi induced by bacterial toxins. This clinical manifestation should be distinguished from true bacterial invasion of the posterior orbit, which may require more aggressive surgical treatments such as exenteration.
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Affiliation(s)
- Bülent Yazıcı
- Uludağ University Faculty of Medicine, Department of Ophthalmology, Bursa, Turkey
| | - Huri Sabur
- Uludağ University Faculty of Medicine, Department of Ophthalmology, Bursa, Turkey
| | - Fatih Toka
- Uludağ University Faculty of Medicine, Department of Ophthalmology, Bursa, Turkey
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Abstract
This article provides an overview of rare orbital diseases. Congenital
malformations, inflammatory diseases, benign and malignant neoplasias are
described. Although it represents a relatively small area of the body the
orbit contains multiple different tissues. Therefore, a great variety of
diseases can be found within the orbital space. That is the reason, why both
the completeness and the level of detail in the description of particular
diseases must be somewhat limited. Nevertheless, clinical manifestations,
important aspects of diagnosis, treatment strategies, and, when specific
data are available, the prognosis are described. The authors tried to
highlight the most characteristic aspects of the different diseases to
describe their relevant aspects in spite of the brevity of the
subsections.
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Affiliation(s)
- Ulrich Kisser
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Halle/S. (Klinikdirektor: Prof. Dr. med. S. Plontke)
| | - Jens Heichel
- Universitätsklinik und Poliklinik für Augenheilkunde, Halle/S. (Klinikdirektor: Prof. Dr. med. A. Viestenz)
| | - Alexander Glien
- Universitätsklinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Halle/S. (Klinikdirektor: Prof. Dr. med. S. Plontke)
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