Diagnostic dilemma: Girl's dental trouble caused a life-threatening eye infection

The patient: A 6-year-old girl in the West Bank

The symptoms: The girl was brought to her primary dentist because she had a toothache near her back-right molars, along with a headache, swelling around her right eye, and a fever of 104 degrees Fahrenheit (40 degrees Celsius). She received acetaminophen to reduce her temperature and oral antibiotics to fight the infection, but the swelling worsened. Following two episodes of vomiting, she was admitted to a hospital pediatric ward.

What happened next: Doctors gave the patient intravenous antibiotics, including vancomycin, which is often used for hard-to-treat bacterial infections, including those caused by methicillin-resistant Staphylococcus aureus (MRSA). Her condition did not improve. The eye began to bulge from the socket, and she developed double vision and light sensitivity. She could move this eye only a little, and the area around it was severely swollen, shiny, flushed and warm to the touch. Her left eye was also mildly swollen, but she could still freely move that eye.

A CT scan of the patient's head showed that her right sinus cavities were so inflamed that they appeared opaque on the scan. A closer look revealed swollen tissues that displaced fat layers around the eye. There was also an accumulation of pus in the eye socket — known as a subperiosteal abscess, doctors wrote in a report of the case.

The diagnosis: Ophthalmologists determined that the girl's eye swelling was caused by a bacterial infection known as orbital cellulitis, which affects fat and muscle tissues around the eye but not the eye itself. It can cause permanent vision loss by damaging blood vessels and nerves in the eye. If untreated, the infection can spread to the bloodstream or brain, leading to life-threatening complications. The doctors determined that bacteria had migrated from the patient's original infection in her teeth to her sinuses, and had then spread to her eye.

Prior to 1985, orbital cellulitis was commonly linked to the bacterium Haemophilus influenza. Since the development of a vaccine for H. influenza type b, however, orbital cellulitis is usually caused by S. aureus (also known as staph) and various species of Streptococcus.

The treatment: Because orbital cellulitis can cause blindness and other dangerous complications, the doctors surgically removed the abscess to relieve the pressure on the patient's eye. Several days later, surgeons operated again and extracted two infected teeth: the first and second molars on the right side. They created a drainage opening in the patient's sinuses and removed several polyps that had formed in her sinus cavity. She continued to receive intravenous antibiotics, and her condition quickly improved. At a follow-up visit eight months later, her eye appeared normal, with no loss of vision or mobility.

What makes the case unique: Orbital cellulitis is much less common than periorbital cellulitis, a superficial eye infection that typically only affects the skin around the eye. In a study that reviewed 10 years of data from children hospitalized for eye infections, orbital cellulitis made up only 17% of the cases.

In children, about 90% of orbital cellulitis cases stem from sinus infections, and the condition is very rarely caused by dental issues. To date, only four such examples have been described in the medical literature, according to the report authors.