November 2003

An 8-year-old girl was transferred from another hospital emergency department (ED) for evaluation and treatment of fever and painful swelling of her nose and both eyes. The onset of her problem began three days earlier with a small sore in the left nostril that was described as a pimple that itched. It soon began to hurt and had associated swelling. The day prior to admission, she was evaluated and treated with a shot of ceftriaxone and given oral amoxicillin-clavulanate (Augmentin, GlaxoSmithKline) and cetirizine (Zyrtec, Pfizer). By the next morning, the pain and swelling was worse and she was again seen at the local ED and transferred.

Her past medical history was unremarkable. She had never been admitted to the hospital for any prior illness or injury. Her immunizations were up to date. She denied any trauma to her nose or face. She had no known allergies.

Examination revealed a normal 8-year-old girl with a fever of 101.9° F and marked swelling of her face, including her nose and surrounding soft tissue (figures 1 and 2). Her left nostril was noted to have a cluster of pustules on the anterior septum (figure 3).

Her admission complete blood count revealed a white blood cell count of 15,100 with 65% granulocytes. A CT scan of her face and orbits showed only soft tissue swelling.

Of the following, what's your initial therapy?

1. Intravenous steroids
2. Nafcillin
3. Clindamycin plus cefuroxime (Zinacef, GlaxoSmithKline)
4. Vancomycin plus ceftriaxone (Rocephin, Roche)

Answer

The answer is 4, vancomycin plus ceftriaxone. This patient had cellulitis of the mid-face as shown. The port of entry for the organism was likely the anterior septum, where the pustule was located. These infections carry an increased risk of developing life-threatening intracranial complications like cavernous sinus thrombophlebitis, as shown in figure 4: a patient who also had an infection that began on his nose. Most of these infections are caused by Staphylococcus aureus. Today when faced with a serious staph infection, vancomycin should be selected until culture and sensitivity results are known.

MRSA

Even though she had no evidence of extension to the central nervous system (CNS), I recommended starting with a dose of 60 mg/kg/day divided every six hours, as if treating a CNS infection, and adjusting the dose according to the levels. Since gram-negative bacilli can also be a cause of these infections, it is reasonable to add another antibiotic, again pending culture results. I think a good choice is a third-generation cephalosporin, like ceftriaxone. While other choices are equally acceptable, this is the combination we picked for this patient. An otolaryngology consult was also obtained, and she was urgently taken to surgery, where a large amount of purulent material was drained from an abscess in the septum near the pustule. The culture grew methicillin-resistant S. aureus (MRSA) that was clindamycin-sensitive by “D” test (as discussed in the April 2003 issue of this newspaper). The ceftriaxone was discontinued and IV vancomycin was continued for a total of three days. At that time she had improved significantly (figures 5 and 6), and was switched to oral clindamycin to finish a three-week course of therapy per otolaryngology request. Follow-up revealed complete resolution.

With the now common occurrence of community-acquired MRSA infections, we frequently start treatment of possible MRSA infections with clindamycin. However, I would not recommend beginning with clindamycin when dealing with a potentially more serious infection, especially if there is a possibility of CNS extension. Clindamycin does not penetrate the blood-brain barrier well enough. The same can be said of cefuroxime. This is a second-generation cephalosporin that was widely used in the 1980s in pediatric facial infections and meningitis, until it was found that cefuroxime was associated with delayed sterilization of the cerebrospinal fluid in meningitis patients. While effective against most other infections caused by methicillin-sensitive strains of S. aureus, cefuroxime has largely been replaced by more narrow-spectrum antibiotics. Its main advantage 20 years ago was its use as an anti-Haemophilus influenzae type b (Hib) antibiotic as well as its activity against pneumococcus, staph and some common gram-negatives. Now, with Hib being almost unheard of in fully immunized children, it is not necessary to empirically treat for this organism anymore. Also, this patient’s age was beyond that which we historically saw in Hib infections.

For staph infections that are potentially life-threatening, nafcillin should be used only when sensitivities are known.

Steroids were thrown in to try to trick anyone thinking this was an allergic reaction, like poison ivy (figures 7 and 8; both patients admitted for treatment of facial cellulitis). The pustule, pain and fever should be the tipoff that it is an infection.

Influenza season

P.S.: Remember, influenza season is rapidly approaching. As of this writing, a known outbreak is being investigated near Houston. We should have our high-risk patients immunized by now, and since there is no shortage of vaccine this year, there is no need to delay anyone wanting to be protected. Also, remember the nasal spray influenza vaccine (FluMist, Wyeth, MedImmune) is now available for healthy patients 5 through 49 years of age. (ACIP does not recommend FluMist for health care workers with patient contact.) However, they will probably have to pay for it as few if any insurance providers will pay the extra cost (I was quoted a wholesale price of about $45). For many, however, it may be worth it. Depending on the schedule used, most children receive about 20 sticks by their second birthday and can develop quite a fear of needles. If my children were young and eligible, I would pay the extra cost to avoid having them take another stick. However, since they are all grown up now (figure 9), they can take the shot just like me, or pay for it themselves. Of course, they would get me back in countless other ways, so I’ll probably end up paying for it anyway.

By the way, for anyone interested in a fascinating look at the influenza pandemic of 1918, I would recommend the book Flu by Gina Kolata. She is a science reporter for The New York Times and published the book in 1999. She does a very nice job of reviewing the pandemic (complete with great pictures), and the more recent search for the virus that caused it.

To everyone, have a safe and happy Thanksgiving, and remember our troops deployed to dangerous places around the world. Their turkey will probably come out of a can.

For more information:

• James H. Brien, DO, Pediatric Infectious Disease, Scott and White’s Children’s Health Center and Associate Professor of Pediatrics, Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbrien@aol.com.