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.