EM Case of the Week - Did we see this diagnosis coming?
-Dr. Yvonne Giunta
1st visit:
13-year-old male presents to the ED for evaluation of 1 day of left eye pain with fever. He denies any trauma to the area or any discharge coming from the eye. Exam is impressive for left upper eyelid edema with tenderness to palpation of the eyelid, no erythema of the eyelid, no pain with eye movement. Patient was diagnosed with preseptal cellulitis and discharged on oral Cefdinir.
2nd visit:
Patient returns to the ED the following day for evaluation of worsening left eye pain with increased swelling. He took a dose of the antibiotic as prescribed and immediately vomited afterwards. Patient denies any pain with eye movement or discharge coming from the eye. Fever Tmax 101. Exam is impressive for left upper eyelid swelling, now with erythema. Plan: Change antibiotic to Cephalexin for management of preseptal cellulitis.
3rd visit:
Patient returns to the ED about 2 weeks later for now worsening of left eye swelling with puffiness of his forehead. Patient states that he completed the course of Cephalexin for 10 days. Symptoms had temporarily resolved and fever had resolved but 2 days ago, symptoms returned and were even worse. Tmax 103. Exam is impressive for left eyelid swelling with tenderness to palpation and drooping of the left eyelid, no ophthalmoplegia, + difficulty with exotropia. Bilateral upper and lower eyelid swelling with erythema, worse on the left side. Left side of forehead with mild nonpitting edema and tenderness to palpation, no proptosis.
Pertinent Labs/Imaging:
ESR 25
CRP 71.2
WBC 16.3
Blood Culture negative
CT orbit: Left frontoethmoidal sinusitis complicated by subdural empyema and overlying frontal scalp\periosteal phlegmon\early abscess
Consulted neurosurgery, ophthalmology, ENT, ID
Treatment with IV vancomycin and IV meropenem
Progression of case… Patient transferred to Cohen Children's Medical Center for left supraorbital craniotomy into frontal sinus and frontal epidural abscess. Subperiosteal cultures grew Streptococcus intermedius.
Diagnosis:
Pott's Puffy Tumor
I encourage you to click to link below and read up more on Pott's Puffy Tumor. Some main points from attached link:
Pott’s Puffy Tumor is Forehead Swelling due to Subperiosteal Edema / Abscess / Granulation tissue.
Typical results from frontal bone osteomyelitis.
Has been considered “rare” in the post-antibiotic era.
It has, however, been reported at a greater rate recently.
Anatomy Matters:
Adolescents most often affected due to anatomic changes.
Mean age of one study = 13 years and 3 months
Often diagnosed after an average of 7 days of fever!
Initial presentation may not be specific.
Unfortunately, delayed presentation and diagnosis may lead to increased complications.
Most have intracranial involvement upon diagnosis.
Moral of the Morsel
It’s not gone, so don’t let it be forgotten! Pott’s Puffy Tumor is still an entity that can develop and needs to remain on our Ddx lists.
Not all sinusitis has rhinorrhea and nasal congestion! That severe forehead pain may be the only early clue to frontal sinusitis developing into osteomyelitis.
Forehead Swelling? Yeah, that ain’t normal! Unfortunately, by the time this develops, the likelihood of other local extension is high. Get that CT with Contrast first!