CLINICAL HISTORY:

Signs and symptoms:  Her condition began as a suspected “bug bite which has just grown to involve the entire eye.?Part of the lesion had blistered and some oozing was noted, but no ulceration. The patient denied recent URI, fever, vision changes, ptosis or photophobia. She described some scant AM discharge from her eye without purulence.

Previous Treatment: 

Other information:  Past Medical History: Hysterectomy/BSO 30 years prior, no other medical history. No history of malignancy, diabetes or immunosupression. No history of rosacea or seborrheic dermatitis.

Medicines: Other than mentioned above; multivitamin and Aspirin, 81mg qd. No use of herbal or other OTC medicines.

Allergies: No known drug allergies

PHYSICAL EXAM:

(fig. 1,2) No fever. Poorly demarcated erythematous plaque with fine scale and crust involving both eyelids and periorbital skin of the left eye. No proptosis or photophobia noted. Extra ocular movements intact. Pupils were equal, round and reactive. No corneal defects noted. No adenopathy noted.

Figure 1

Figure 2

LABORATORY TESTS:

DERMATOHISTOPATHOLOGY:

Figure 3

DIFFERENTIAL DIAGNOSIS:

1.   Preorbital (preseptal) cellulitis
2.   Orbital (septal) cellulitis
3.   Blepharitis
4.   Contact dermatitis
5.   Herpes Zoster Ophthalmicus

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Contact dermatitis

DISCUSSION:

The goal of this case is to trust the findings of your physical exam. One would certainly not want to miss the diagnosis of orbital cellulitis or herpes zoster ophthalmicus- but there was nothing in the history or physical exam to support these diagnoses.

Orbital cellulitis often results from contiguous spread from the paranasal sinuses. There is often a preceding history of URI or sinusitis. The presentation often includes pain, erythema, proptosis, decreased motility and acuity, afferent pupillary defect, fever and leukocytosis. Usually blood cultures are negative. Complications include septic cavernous sinus thrombosis and meningitis. This requires a hospital admission with STAT Ophthalmology consult, IV antibiotics, orbital imaging and appropriate lab work.

Preorbital cellulitis presents with pain and erythema around the orbit without the ophthalmologic symptoms. As above, an Ophthalmology consult is needed with appropriate antibiotics, imaging, and careful monitoring for the progression to orbital cellulitis.

Blepharitis is inflammation of the eyelids, usually in association with rosacea or seborrheic dermatitis. The eyelid margins are greasy, ulcerated and crusty. These ulcers are usually colonized with staphylococcus. Treatment involves addressing the underlying condition, warm compresses and topical antibiotics.

Herpes Zoster Ophthalmicus represents V1 nasocilliary branch involvement of varicella zoster virus reactivation. Multiple lesions in various stages of development (vesicles, pustules, erosions, crusts) grouped in a herpetic distribution along one dermatome are characteristic. Often, the classic vesicle on erythematous base can involve the tip of the nose (Hutchinson’s sign). An ophthalmologic evaluation is needed to evaluate corneal involvement. The diagnosis is clinical, although a Tzanck smear or PCR can be utilized to confirm. Therapy is antivirals, cycloplegics, and possibly corticosteroids.

TREATMENT:

The diagnosis of allergic contact (eyelid) dermatitis was made in this case based on the history and physical exam. Allergic contact dermatitis is the result of a type IV delayed hypersensitivity reaction to a previously sensitized allergen. Histopathologic features of acute allergic contact dermatitis include spongiosis, intraepidermal vesicles, bullae and exocytosis of lymphocytes. There is a mixed dermal infiltrate including a variable amount of eosinophils. (fig. 3A). Chronically these features are replaced by psoriasiform hyperplasia (fig. 3B).

Eyelid dermatitis may be caused by atopic dermatitis, substances transferred to the eyelid from the hands (nail polish), cosmetics or hair products. The patient was instructed to discontinue all topical therapy, apply pimecrolimus cream B.I.D. and to follow up the following day to check progress and to bring in the topical medicines she had been using. The patient was instructed to notify the office immediately if she experienced any fever or ophthalmologic symptoms. The following day, the patient reported she had been using Neosporin:

Active Ingredients: Each gram contains: Polymyxin B Sulfate (5,000 units), Bacitracin Zinc (400 units), Neomycin (3.5 mg)

Inactive Ingredients: Cocoa Butter, Cottonseed Oil, Olive Oil, Sodium Pyruvate, Tocopheryl Acetate, White Petrolatum

The patient was informed she likely had an allergic response to neomycin, as it is the most common sensitizer among topical antibiotics. Co-reactivity is commonly seen between neomycin and bacitracin; this is due to co-sensitization from their frequent use in combination rather than cross reactivity. Neomycin and bacitracin were added to her allergy list and at six weeks her eczematous patch had evolved into post inflammatory hyperpigmentation (fig. 4)

Figure 4

REFERENCES:

1. Odom, Richard B, et al. Andrew’s diseases of the skin: clinical dermatology 9th Ed. Philadelphia: WB Saunders Co. 2000.

2. Bolognia, J,L, et al. Dermatology 1st Ed. Philadelphia: Mosby, 2003.

3. Braunwald, E, et al. Harrison’s principles of internal medicine 15th Ed. New York: McGraw Hill. 2001.

4. Albert MR, Gonzalez S, Gonzalez E., Patch testing reactions to a standard series in 608 patients tested from 1990 to 1997 at Massachusetts General Hospital. Am J Contact Dermat. 1998 Dec;9(4):207-11.

Additional Comment:

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