A 19-year-old woman presents with 5 days of progressive swelling around her right eye. She reports a week of prior nasal pain. On examination, her right eyelid is swollen, the globe is proptotic, and eye movement is limited by pain. Visual acuity is intact. Vital signs are:
A CT scan demonstrates inflammation of extraocular muscles, fat stranding, and anterior displacement of the globe, with frontal sinusitis. There is no evidence on CT of intracranial inflammation, nor any vascular compromise. While awaiting the results of blood cultures, which of the following antibiotic regimens is MOST appropriate to administer at this time?
Correct Answer: C
This patient’s clinical presentation and CT findings are characteristic of orbital cellulitis, an infection involving the contents of the orbit. Orbital cellulitis may cause loss of vision and even loss of life. It is distinguished from preseptal cellulitis (a less severe infection of the anterior portion of the eyelid) by ophthalmoplegia, pain with eye movements, proptosis, and characteristic findings of infection on CT including inflammation of extraocular muscles, fat stranding, and anterior displacement of the globe. CT or MR venography should also be performed to rule out cavernous sinus thrombosis. Most patients with uncomplicated orbital cellulitis can be treated with antibiotics alone. A broad-spectrum regimen should be administered to target Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus [MRSA]), Streptococcus pneumoniae, and other streptococci, as well as gram-negative bacilli. When intracranial extension is suspected, the regimen should also include coverage for anaerobes. Of the options provided for this patient, vancomycin and ceftriaxone would be the most appropriate coverage regimen. Levofloxacin or piperacillintazobactam alone or the combination of vancomycin and metronidazole would not be broad enough to cover likely pathogens. Moreover, since there is minimal concern for intracranial involvement, the anaerobic coverage of metronidazole is not needed.
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A 55-year-old male with no medical history presents with headache which has lasted for the last 8 days. Approximately 2 weeks ago, he had a furuncle adjacent to the right nares drained. This morning he developed fever, diplopia, and right eye ptosis. On examination, he is febrile to 38.4°C, somnolent but arousable, and hemodynamically stable. He has ptosis and proptosis of the right eye, with a dilated pupil. Neurologic examination shows right third and fourth nerve palsy and decreased sensation on the right side of his face. A highresolution CT scan with contrast shows regions of decreased enhancement, thickening of the lateral walls, and bulging of the cavernous sinus.
Which is the MOST likely causative organism of the infection?
Correct Answer: B
This patient presents with concern for septic cavernous sinus and thrombosis. The multiple trabecula of the cavernous sinus acts as sieves to trap bacteria and consequently makes it the most frequent dural sinus to become thrombosed. Infections of the face including the orbit (orbital cellulitis), around the nose, and soft palate can spread to the cavernous sinus from the facial veins and the pterygoid plexus. In this patient, bacterial spread likely resulted from the drained furuncle. Cranial nerves III, IV, ophthalmic (V1 ) and maxillary(V2 ) branches of the trigeminal nerve, and VI all travel through the cavernous sinus. Headache and cranial nerve deficits should alert the clinician to the possibility of this condition. CT or MR venography can readily identify septic cavernous sinus thrombosis characteristically demonstrating regions of decreased or irregular enhancement, thickening of the lateral walls, and bulging of the sinus.
The causative organism reflects the primary site of infection. Staphylococcus aureus accounts for 70% of all infections, and communityacquired MRSA is increasingly reported. Less commonly streptococci (Streptococcus pneumoniae) are found. Anaerobes (Fusobacterium, Bacteroides) most often occur with dental or tonsillar infections. Fungal pathogens (Rhizopus) have been reported but are quite rare. High-dose intravenous antibiotics against the most probable organisms should be instituted promptly and continued for a prolonged period (at least 3 weeks) to ensure sterilization.
A 28-year-old woman presents with increasing pain and progressive swelling of her neck over the last day. She recently underwent a dental extraction for an abscess but did not complete her course of antibiotics. She denies any respiratory difficulty or distress. On examination, her neck is inflamed, erythematous, with areas of fluctuance and crepitus on palpation. She is to be taken emergently for surgical debridement.
After cultures are obtained in the operating room, what is the MOST appropriate antibiotic regimen to administer?
Correct Answer: D
The finding of severe pain, fluctuance, and crepitus in the setting of recent infection is typical of a necrotizing soft-tissue infection. Necrotizing soft-tissue infection is a surgical emergency that requires immediate debridement. Necrotizing soft-tissue infections of the head and neck infection can rapidly spread leading to mediastinitis and possibly death from associated complications. These infections can result from a disruption in the oropharyngeal mucus membrane such as following surgery for a dental infection. The infection is usually polymicrobial caused by mouth anaerobes (fusobacteria, anaerobic streptococci, Bacteroides). Monomicrobial infections due to group A Streptococcus can also occur. Empiric treatment of a necrotizing infection is three-pronged and should include:
A 55-year-old male with acute respiratory distress syndrome (ARDS) and ventilator-associated pneumonia (VAP) due to a pansensitive Klebsiella continues to have fevers and a persistently elevated white blood cell count. Blood, sputum, and urine cultures remain negative. His medical history includes prior chest radiation, atrial fibrillation currently managed with a heparin gtt, and a prior cholecystectomy. He is tolerating tube feeding via a nasogastric tube and has solid formed stool.
Which of the following diagnostic tests is MOST likely helpful?
Correct Answer: A
This patient has evidence of infection despite treatment for VAP. Of the options provided, sinusitis is the most plausible etiology given the clinical presentation. Risk factors in ICU patients for nosocomial sinusitis include endotracheal intubation, nasal colonization with gram-negative organisms, and enteral feeding via a nasogastric tube. Nosocomial sinusitis should be suspected in all intubated patients who have a fever without an obvious source, especially if there is purulent nasal drainage. CT is more sensitive than plan radiography and will show sinus opacification. Culture of sinus fluid is the gold standard for diagnosis. The pathogenic organisms are similar to those causing VAP (Staphylococcus aureus, Streptococcus, Klebsiella, and other gram-negative bacilli). Treatment involves systemic antibiotics targeted against the pathogen grown from sinus fluid culture. Initial treatment should broadly target the common pathogens similar to initial antibiotic choices for VAP. Adjunctive therapies include saline irrigation, removal of nasal tubes, and nasal decongestants. Right-upper-quadrant ultrasound would be of little use in this patient as he has had a cholecystectomy and therefore does not have acalculus cholecystitis. He is tolerating tube feeding and has solid, formed stool making C. difficile infection extremely less likely. Although deep venous thrombosis may be a cause of persistent fevers, he is already therapeutically anticoagulated with heparin.
A 43-year-old man presented to the emergency department with complaints of dysphagia and fever. He has felt ill and unable to eat for 2 days. He has a history of type 2 diabetes and reports frequent alcohol use. On examination, he is noted to have poor dentition and is drooling. The floor of the mouth is firm, and the submandibular glands are enlarged and tender. Laboratory testing reveals a leukocytosis to 20,000. He is treated with ampicillin-sulbactam and clindamycin and admitted to the ICU. Over the next 4 hours, he complains of increasing tongue swelling and shortness of breath.
Which of the following is the more appropriate next step in management?
This patient presents with an infection of the submandibular space (Ludwig angina). This acute condition can progress to critical airway compromise, making intubation extremely difficult. This bacterial infection often occurs after a tooth abscess but can also follow other mouth infections or injuries. It is more common in patients with diabetes and neutropenia. Common presenting signs and symptoms include dysphagia, mouth pain, drooling, and fever. The submandibular tissues are classically described as “woody,” not fluctuant, often without any true drainable collection. Typical pathogens include mouth anaerobes (Fusobacterium), streptococci, or Staphylococcus aureus, and initial antibiotics should broadly target all of these organisms, including MRSA. If untreated, the infection can progress with necrosis of the tongue, aspiration, and death from airway obstruction. If the airway becomes compromised, a surgical airway (tracheotomy or cricothyroidotomy) is typically recommended as first line for airway management. Direct laryngoscopy may be exceedingly difficult and attempting it in a resource-limited environment such as the ICU may lead to further complications. Bronchodilators are unlikely to relieve the airway obstruction. While drainage may be indicated, this patient is acutely decompensating, and the airway should be secured before attempting further procedures.
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