Case Description:
A 36-year-old male with history of asthma, hypertension, uncontrolled
diabetes, and obesity presented with sudden onset of redness and
swelling in the right eye that started 6 days prior to hospitalization,
and was gradually getting worse. He initially went to an urgent care
where he was prescribed cephalexin 500 mg twice a day. After 2 days, he
did not notice significant relief, and developed a new blurry vision
associated with photophobia in the right eye. Later, he spiked a fever
of 103oF at which point he decided to come to the
hospital, and got admitted. He denied reports of trauma, local injury,
swimming pool exposure, and use of contact lens. He denied any recent
sick contacts and lives with his spouse and three young kids, none of
whom were sick in recent times. He reported a monogamous relationship
with his wife and denied any history of sexually transmitted diseases.
He denied intravenous drug use, smoking, or alcohol use. He had two pet
dogs, none of whom were sick with similar illness. His vital signs were
stable at presentation except for fever as mentioned above. On
examination, he had severe redness of palpebral conjunctiva with diffuse
sub-conjunctival hemorrhage. Upper and lower right eyelid showed
redness, ecchymoses, swelling, crusting and discharge from the corner of
his right eyelid (Figure 1).
His left eye was normal. Pupils were equally reactive to light on both
sides. Intraocular pressure measured by tono-pen was within normal
limits. Visual field testing showed mild generalized constriction of
visual field of the right eye. Bilateral corneas, anterior chamber,
iris, and lenses were grossly normal without any abnormality.
Fundoscopic examination via indirect ophthalmoscopy after pupillary
dilatation showed normal vitreous, and absence of retinal or optic disc
changes. All cranial nerves were intact and extraocular muscles showed
full range of motion with tenderness on full extension. Motor, sensory
exam, and reflexes were equal and bilaterally symmetrical.
Upon admission, he was started on broad spectrum antibiotics. White
blood cell count, hemoglobin, platelets, serum electrolytes, serum
creatinine, and liver function tests were all within normal limits
except for an elevated blood sugar of 268 mg/dL (normal range [NR]:
70-110 mg/dL). Procalcitonin was normal at 0.04 ng/mL (NR: less than 0.1
ng/mL), erythrocyte sedimentation rate was elevated at 54 mm/hour (NR:
1-13 mm/hour), C-reactive protein was 0.94 mg/dL (NR: less than 1
mg/dL). HIV 1&2 antigen and antibody test were negative. Magnetic
resonance imaging (MRI) of face showed preseptal soft tissue thickening
consistent with cellulitis. Ocular globe, post-septal space, ocular
lenses, extra-ocular muscles, optic nerve sheath, lacrimal glands, and
retro-bulbar fat appeared normal with no involvement from infection
(Figure 2).
Blood cultures returned negative after 5 days of incubation. Serum
sample was sent for microbial cell-free DNA test also known as
meta-genomic testing. It showed 459 DNA molecules per microliter (MPM)
of human adenovirus D in the serum sample with normal range of less than
10 MPM. The patient was started on topical steroids, and he responded
well with significant improvement in signs and symptoms within first 3
days. Antibiotics were discontinued, and the patient was discharged home
with no sequelae at the follow-up visit.