Visual Diagnosis: Periorbital Edema in a 7-year-old Girl

Chantel Cacciotti; Claudia Vicetti Miguel; Jeremy Neuman; Sarah Vaiselbuh

doi:10.1542/pir.2015-0064

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Chantel Cacciotti, MD*
Claudia Vicetti Miguel, MD*
Jeremy Neuman, MD^†
Sarah Vaiselbuh, MD*

^*Department of Pediatrics, Staten Island University Hospital, The Children’s Cancer Center, Staten Island, NY.
^†Department of Radiology, Staten Island University Hospital, Staten Island, NY.

AUTHOR DISCLOSURE
Drs Cacciotti, Vicetti Miguel, Neuman, and Vaiselbuh have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A previously healthy 7-year-old girl presents to the emergency department with a 2-week history of worsening left-sided periorbital erythema, edema, and conjunctival injection. The patient had completed a 10-day course of amoxicillin prescribed for presumptive periorbital cellulitis without clinical improvement. Her parents deny any history of fever, recent respiratory tract infections, insect bite, or trauma. She has had no sick contacts. She denies polyuria, polydipsia, weight changes, diarrhea, or vomiting.

Physical examination reveals left periorbital erythema with temporal soft-tissue swelling that is tender to palpation. The conjunctivae are injected without discharge, sclera are clear, and no proptosis is evident. Extraocular movements are normal. Visual acuity is 20/20 in both eyes.

Results of a complete blood cell count, complete metabolic profile, and urine homovanillic acid and vanillylmandelic acid measurement are within normal limits. C-reactive protein and erythrocyte sedimentation rate are mildly elevated at 20.8 mg/L (198.1 nmol/L) and 38 mm/hr, respectively. Orbital computed tomography (CT) scan reveals an erosive left superolateral orbital bone lesion with a soft-tissue component extending to the postseptal extraconal orbit, the lacrimal gland, and the epidural space (Figs 1 …