PATIENT AND OBSERVATION
The patient was a 14-year-old girl living in the commune of Kadutu in the city of Bukavu. Her parents brought her to the University Clinics of Bukavu pediatric emergency room for painful swelling and protrusion of the left eye, which had been developing for several days following nasopharyngitis. She was treated at home with a diclofenac tablet without success.
The complementary history revealed headaches and a notion of a recurrent cold. The physical examination revealed a change in the general state due to a decrease in physical activity as well as a high fever of 39.9° Celsius, a sensitive swelling of the left upper eyelid and the external canthus, chemosis, and left exophthalmos with preservation of ocular mobility and visual acuity (10/10) with a normal fundus and sensitivity to compression opposite the ethmoidal and maxillary sinuses (Figure1).
The blood count revealed hyperleukocytosis at 17700/mm3 with 93% neutrophilic predominance and significantly elevated inflammatory markers at 107 mg/L and 5.04 ng/ml, respectively, for CRP and Pro-Calcitonin. Ethmoid-orbital and brain CT scans revealed acute ethmoiditis with left maxillary sinus involvement complicated by a left superior-lateral intraorbital abscess (22×13×12mm) (Chandler Classification IV) (Figure2) and a right-predominant medial frontal brain empyema (25×14×10mm) without involvement.
The diagnosis of acute ethmoiditis complicated by intraorbital abscess, orbital cellulitis and cerebral empyema was made.
A parenteral treatment of Ceftriaxone (100mg/kg/day), Ciprofloxacin (30mg/kg/day) associated with a regressive dose of prednisone tablet at a rate of 0.5mg/kg/day and an instillation of Cefindex collyre (Dexamethasone and ciprofloxacin) was initiated. After 48 hours of treatment, the evolution was marked by apyrexia and significant regression of headaches on the one hand, and by the aggravation of the swelling of the left eyelid, exophthalmos with the occurrence of exposure keratitis on the other hand. At 72 hours of treatment, metronidazole infusion (30 mg/kg/day) and artificial tears were added to his treatment. On the seventh day, the orbital abscess was collected and drained under local anesthesia (Lidocaine) via an external route passing under the left superciliary arch. In pyoculture, no germs grew.
At 72 hours after drainage of the abscess, we noticed a complete regression of the left exophthalmos, complete resorption of the bilateral swelling of the eyelids, and chemosis (figure3). On the fourteenth day of treatment, the control blood tests requested showed good paraclinical evolution with a decrease in the hyperleukocytosis as well as the initially elevated inflammation markers (Table I). The patient was discharged under an oral treatment made of Augmentin tablets (80mg/kg/day), Metronidazole tablets (30mg/kg/day), and corticosteroid therapy (prednisone) at a regressive dose for seven days.