Pneumococcal Facial Cellulitis in Children Laurence B. Givner, MD*; Edward O. Mason, Jr, PhD‡; William J. Barson, MD§; Tina Q. Tan, MDi; Ellen R. Wald, MD. Facial cellulitis includes both periorbital. Department of Pediatrics, Wake Forest University School of Medicine, Medical Center. PDF. Table of Contents; Early. Pneumococcal Facial Cellulitis in Children | ELECTRONIC ARTICLEAbstract. Objective. To review the epidemiology and clinical course of facial cellulitis attributable to. Streptococcus pneumoniae in children. Design. Cases were reviewed retrospectively at 8 children's hospitals in the United States for the period of September 1. December 1. 99. 8. Results. We identified 5. Ninety- two percent of patients were < 3. Most were previously healthy; among the 6 with underlying disease were the only 2 patients with bilateral facial cellulitis. Fever (temperature: ≥1. F) and leukocytosis (white blood cell count: > 1. Two of 1. 5 patients who underwent lumbar puncture had cerebrospinal fluid with mild pleocytosis, which was culture- negative. All patients had blood cultures positive for S pneumoniae. Serotypes 1. 4 and 6. B accounted for 5. Overall, 1. 6% and 4% were nonsusceptible to penicillin and ceftriaxone, respectively. Such isolates did not seem to cause disease that was either more severe or more refractory to therapy than that attributable to penicillin- susceptible isolates. 1 Created by Carrie Rassbach, MD LPCH Pediatric Hospitalist May, 2011 Periorbital and Orbital Cellulitis Summary Definitions: Periorbital and orbital cellulitis are. Overall, the patients did well; one third were treated as outpatients. Conclusions. Pneumococcal facial cellulitis occurs primarily in young children (< 3. Conclusions. Pneumococcal facial cellulitis occurs primarily in young children (<36 months of age) who are at risk for pneumococcal bacteremia.Management of preseptal and orbital. patients admitted for management of preseptal and orbital cellulitis. cellulitis in childhood. Pediatrics, 62. Cellulitis and erysipelas manifest as areas of skin erythema, edema, and warmth. Editor-in-Chief — Pediatrics Section Editor — Pediatric Infectious Diseases. Orbital cellulitis should be suspected in any patient with adnexal, facial, or dental infection when orbital pain, proptosis, limitation of ocular motility. Practice Guidelines for the Diagnosis and Management of Skin and Soft. An etiologic diagnosis of simple cellulitis is. American Academy of Pediatrics, 2003. They present with fever and leukocytosis. Response to therapy is generally good in those with disease attributable to penicillin- susceptible or - nonsusceptible S pneumoniae. Ninety- six percent of the serotypes causing facial cellulitis in this series are included in the heptavalent- conjugated pneumococcal vaccine recently licensed in the United States. Facial cellulitis includes both periorbital (preseptal) and buccal cellulitis. When associated with trauma or contiguous infection (eg, stye), Staphylococcus aureus or Streptococcus pyogenes are likely causes. In the absence of trauma or contiguous infection, historically Haemophilus influenzae type b was the most common cause followed by. Streptococcus pneumoniae. Since the virtual eradication of invasive disease caused by H influenzae type b in the United States through the use of conjugated vaccines, S pneumoniae now likely predominates in such cases. In view of this and the dramatic increase in antibiotic resistance noted among S pneumoniae isolates beginning in the early 1. S pneumoniae among children seen in recent years at 8 children's hospitals in the United States. METHODSThe US Pediatric Multicenter Pneumococcal Surveillance Group consists of investigators from 8 children's hospitals. Since 1. 99. 3, these investigators have prospectively identified children seen at their centers with invasive disease attributable to S pneumoniae (documented by isolation from a normally sterile body site). For the current study, further information was gathered retrospectively for each case of facial cellulitis identified from September 1, 1. December 3. 1, 1. The pneumococcal isolates from each center were sent to a central laboratory (Infectious Disease Research Laboratory, Texas Children's Hospital, Houston, TX) where serotyping and susceptibility testing for penicillin and ceftriaxone were peformed. Isolates were serotyped by the capsular swelling method using commercially available antisera (Statens Seruminstitut, Copenhagen, Denmark; Daco, Inc, Carpinteria, CA). Susceptibility testing was performed by standard microbroth dilution with Mueller- Hinton media supplemented with 3% lysed horse blood. Susceptibility was defined according to the 1. National Committee for Clinical Laboratory Standards guidelines for minimal inhibitory concentrations. L, susceptible; . L, intermediate; ≥2. L, resistant: for ceftriaxone, ≤. L, susceptible; 1. L, intermediate; and ≥2. L, resistant. Isolates that were intermediate or resistant were considered nonsusceptible. The statistical significance of differences in the frequencies of categorical variables was tested with either Fisher's exact test or χ2 test for trends. Two- tailed Pvalues <. RESULTSDuring the study, 5. Forty- five had periorbital and 7 had buccal cellulitis. They ranged in age from 6 weeks to 6 years with a median age of 1. Forty- eight (9. 2%) were < 3. Thirty- four patients (6. Thirty- two patients were white, 1. Hispanic. Ten patients attended day care, 3. Underlying illnesses included: cancer (4), human immunodeficiency virus type 1 infection (1), and facial cystic hygroma (1). Only 2 patients had bilateral facial cellulitis (both periorbital) and both had underlying disease: acute lymphocytic leukemia (1) and human immunodeficiency virus (1). Thus, both of the patients with bilateral cellulitis had an underlying disease/immunodeficiency versus 4 of 5. P = . 0. 1). Recent previous trauma to the affected area was noted in 3 patients and contiguous infection in 2 (stye [1] and dacryocystitis [1]). The onset of cellulitis was preceded by symptoms of upper respiratory tract infection (rhinorrhea, cough, and/or congestion) in 2. Such symptoms were present in 2. Fourteen patients had concomitant otitis media: 1. P = . 3. 6). Six of these involved the ipsilateral ear, 3 the contralateral ear, and in 5 both ears were involved. The 3 patients with buccal cellulitis had otitis media in ipsilateral, contralateral, and bilateral ears, respectively. All patients but 1 had a history of fever. Temperature was documented at the time of presentation for 5. F); 2. 9/5. 0 (5. F and ≥1. 03°F, respectively. The cellulitis was noted to have a violaceous hue in 6 cases. White blood cell count was measured at the time of presentation in 5. The white blood cell count was > 1. Fifty patients had white blood cell differential counts performed that revealed: mature neutrophils, mean 5. Eighteen patients (3. Fifteen patients underwent lumbar puncture; 1. All cerebrospinal fluid (CSF) test results were normal except for pleocytosis that was noted in 2 patients with periorbital cellulitis (Table 1). These 2 patients had blood cultures positive for penicillin- and ceftriaxone- susceptible pneumococci. All CSF Gram- stains and cultures were negative for bacteria. Table 1. Patients With Facial Cellulitis and Abnormal CSF Findings. Ten patients (all with periorbital cellulitis) had radiologic studies that included the paranasal sinuses (plain radiography, 5; computed tomography, 5). All studies showed abnormalities of the sinuses (thickened mucosa or opacification; no air- fluid levels were noted). The maxillary sinuses were abnormal in all, ethmoids in 8, and pansinusitis was noted in 3 patients. Abnormal findings were bilateral in 7 (including 1 patient with bilateral cellulitis) and unilateral in 3 (the cellulitis was ipsilateral in 2 of these and bilateral in 1). All patients had blood cultures positive for S pneumoniae. One patient also had aspiration of the cellulitis performed, which was culture- positive. Among the 4. 9 isolates submitted for serotyping, the predominant serotypes were 1. B (2. 7%; Table 2). Table 2. Pneumococcal Serotypes Isolated From Patients With Bacteremic Facial Cellulitis. Antibiotic susceptibility testing was performed at the central laboratory for 5. Of the 5. 1 total isolates, 4. For each calendar year of study, the percent of pneumococci that were nonsusceptible to penicillin was 1. During the study, there was not a statistically significant increase in the percent of cases each year attributable to penicillin- nonsusceptible isolates (P = . During the month before presentation with cellulitis, β- lactam antibiotics had been taken by significantly more patients with penicillin- nonsusceptible isolates (3/8, 3. P = . 0. 4). Overall, 1. Among the 3. 5 patients (6. The median duration of hospitalization was 3 days with a range of 1 to 1. Eleven of the 3. 5 patients (3. All patients were treated successfully. The clinical courses of the 3 patients with penicillin- resistant isolates (2 were intermediate and 1 susceptible to ceftriaxone) are outlined in Table 3. All 3 of these patients had periorbital cellulitis. Their clinical courses seem to be similar to patients with penicillin- susceptible isolates. Table 3. Clinical Courses of Patients With Penicillin- Resistant Pneumococci. DISCUSSIONPneumococcus is now likely the most common cause of bacteremic facial cellulitis in children. Our series is by far the largest published to date of pneumococcal facial cellulitis. We have included both periorbital and buccal cellulitis in this series because although there has been much discussion regarding the pathogenesis of each, it is likely that both are associated with pneumococcal bacteremia. Although proposed by some authors, it is unlikely that buccal cellulitis occurs via lymphatic spread from ipsilateral otitis media. Our finding of otitis media in 4. In our series, in 1 of these 3 only the contralateral ear was involved. In the above noted series. H influenzae type b, 3. H influenzaetype b, while nontypeable H influenzae causes otitis media. Similarly, although proposed by some authors, it is unlikely that sinusitis plays a major role in the pathogenesis of periorbital cellulitis. In our series, radiologic studies of the sinuses were abnormal in all 1. Upper respiratory tract symptoms were noted in 5. Further, before the eradication of disease attributable to H influenzae type b, although this organism was commonly noted to cause bacteremic periorbital cellulitis, it is again nontypeable H influenzae that causes sinusitis. Pneumococcal facial cellulitis occurs in patients at high risk for pneumococcal bacteremia, ie, children younger than 3. Of interest, both of the patients in our series with bilateral periorbital cellulitis had underlying immunodeficiency. In patients who present with bilateral facial cellulitis, if an underlying immunodeficiency has not already been diagnosed, an evaluation for such might be considered. Also of interest, a violaceous hue was noted in 6 of our patients with pneumococcal facial cellulitis.
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