EXPERIENCE AND REASON First Reported Case of Neisseria meningitidis Periorbital Cellulitis Associated With Meningitis David V. Chand, MD; Claudia K. Hoyen, MD; Ethan G. Leonard, MD; and Grace A. McComsey, MD ABSTRACT. Cellulitis is a rare manifestation of menin- gococcal disease. We describe the case of a previously healthy 4-month-old female infant who developed perior- bital cellulitis associated with meningococcal meningitis. Pediatrics 2005;116:e874–e875. URL: www.pediatrics.org/ cgi/doi/10.1542/peds.2005-0694; meningitis, meningococcal disease. ABBREVIATION. CSF, cerebrospinal fluid. P eriorbital cellulitis is often caused by Staphylo- coccus aureus or Streptococcus pyogenes after lo- cal trauma. Before universal immunization with conjugate vaccine, Haemophilus influenzae type b was responsible for 80% of cases of bacteremic peri- orbital cellulitis. 1 Here we describe a case of perior- bital cellulitis associated with meningitis caused by Neisseria meningitidis. CASE REPORT A previously healthy 4-month-old Amish female was trans- ferred to our hospital with 2 days of fever, fussiness, decreased oral intake, and decreased wet diapers. Her reported rectal tem- perature was 40.6°C. She had no cough, congestion, or rhinorrhea. On the day of admission, she vomited 3 times but had no change in stool pattern. She had no sick contacts. She had received her first hepatitis B, polio, H influenzae type b, and diphtheria and tetanus toxoids and acellular pertussis vaccines at 2 months of age. There was no family history of invasive bacterial infection. At an outside hospital, the patient had a temperature of 38.4°C, pulse of 170 beats per minute, and a respiratory rate of 42 per minute. She was ill-appearing without localizing signs on exami- nation. A serum basic chemistry was normal except for a glucose level of 155 mg/dL. The complete blood count showed a white blood cell count of 8400/mm 3 , of which 49% were neutrophils, 7% were bands, 33% were lymphocytes, 9% were monocytes, and 2% were atypical lymphocytes; a hemoglobin level of 10.6 g/dL; and a platelet count of 224 000/mm 3 . Cerebrospinal fluid (CSF) anal- ysis showed a protein concentration of 314 mg/dL; a glucose concentration below the assay range (1 mg/dL); a red blood cell count of 650/mm 3 ; and a white blood cell count of 6400/mm 3 , of which 88% were neutrophils, 4% were lymphocytes, and 8% were monocytes. A Gram-stain of the CSF specimen demonstrated many Gram-negative diplococci. Blood and urine cultures were sent. The patient received intravenous ceftriaxone (100 mg/kg per day) and vancomycin (40 mg/kg per day) and was transferred to our facility for additional management. At our hospital she was started on meropenem (120 mg/kg per day), the broad-spectrum antibacterial agent used in our intensive care unit as part of a clinical study protocol, and continued on vancomycin. On arrival, the patient was noted to have developed left periorbital edema and erythema. A computed tomography scan of her head showed normal sinuses and left periorbital edema (Fig 1). An MRI demonstrated left periorbital edema, as well as leptomeningeal enhancement. An ophthalmology consul- tation was obtained, and the examination was also consistent with periorbital cellulitis. The CSF grew N meningitidis serogroup B. Blood and urine cultures remained negative. Total complement function (CH50) was normal. Vancomycin and meropenem were discontinued, and the patient was treated with ceftriaxone (100 mg/kg per day). The patient’s left eye and clinical status im- proved rapidly, but she remained febrile. A repeat MRI on hospi- tal day 9 revealed a small amount of extra-axial fluid along the floor of the middle cranial fossa bilaterally, suggestive of small sterile effusions. Her clinical course was also complicated by bi- lateral hearing loss. Pediatric neurosurgery and otolaryngology consultations were obtained to assist in the management of these complications; no surgical intervention was deemed necessary. She subsequently became afebrile, and an MRI performed 1 week later revealed a smaller fluid collection in the left middle cranial fossa. She was discharged from the hospital after 17 days of intravenous antibacterial therapy. The family and close contacts received the appropriate prophylaxis. DISCUSSION Periorbital cellulitis associated with N meningitidis has rarely been reported. Typically, periorbital cellu- litis is caused by skin flora, predominantly S aureus and S pyogenes, after local trauma. It can also result from a localized infection such as conjunctivitis. Less often, this disease can also be associated with bacte- remia, historically with H influenzae type b and more recently with Streptococcus pneumoniae. 1,2 Donahue and Schwartz 2 have described 70 cases of periorbital cellulitis from 1986 to 1996 at their institution. There From the Department of Pediatrics, Division of Pediatric Infectious Diseases and Rheumatology, Rainbow Babies & Children’s Hospital, Cleveland, Ohio. Accepted for publication Jun 6, 2005. doi:10.1542/peds.2005-0694 No conflict of interest declared. Address correspondence to Grace A. McComsey, MD, Rainbow Babies & Children’s Hospital, Division of Pediatric Infectious Diseases and Rheuma- tology, 11100 Euclid Ave, Cleveland, OH 44106. E-mail: mccomsey.grace@ clevelandactu.org PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad- emy of Pediatrics. Fig 1. A computed tomography scan of sinuses and orbits of the patient demonstrates normal sinuses and left periorbital edema. e874 PEDIATRICS Vol. 116 No. 6 December 2005 www.pediatrics.org/cgi/doi/10.1542/peds.2005-0694 by guest on June 15, 2020 www.aappublications.org/news Downloaded from