【摘要】目的：报告1例罕见的以眼眶脓肿为主要表现，大剂量头孢他定静脉给药治疗成功的类鼻疽。
方法：眼眶类鼻疽病例报告1例。
结果：一名55岁的马来人，新近诊断为糖尿病，低热3wk，左眼肿胀5d入院。头颅及眼眶CT显示左眼眶蜂窝织炎和左侧急性蝶窦炎，最初上眼睑瘘管拭子培养结果为假单胞菌属，给予常规抗生素治疗，患者的全身情况改善。然而随着持续静脉给药，患者全身情况开始恶化，左眼变得更加突出，复查头颅及眼眶CT显示左眼眶脓肿并颅内扩散形成脑脓肿。来自上眼睑侧部瘘管的拭子培养结果显示类鼻疽假单胞菌，急性期采用大剂量头孢他定静脉治疗并口服复方增效磺胺，后采用复方增效磺胺维持治疗2mo治愈，观察1a未见复发。不幸的是患者的左眼视力丧失。
结论：这是1例罕见的由类鼻疽引起的伴发脑脓肿和败血症的眼眶脓肿。在正确诊断的前提下，同时应用大剂量敏感抗生素可有效治疗这种严重疾病。
【关键词】 类鼻疽；眼眶脓肿；脑脓肿；大剂量头孢他定
AbstractAIM: To report a rare case of melioidosis presenting as orbital abscess, who was successfully treated with high dose of intravenous ceftazidime.METHODS: A casereport.
RESULTS: A 55yearold Malay gentlemen who was newly diagnosed with diabetes mellitus, presented with prolonged low grade fever for three weeks and left eye swelling for five days duration. Initial CT scan of brain and orbit showed left periorbital cellulitis and acute left sphenoidal sinusitis. Initial swab culture grew Pseudomonas sp. His general condition improved with regular antibiotics.However, upon completion of intravenous therapy his condition worsened and the left eye became more proptosed. Repeat CT scan of the brain and orbit showed left eye orbital abscess with intracranial extension. Swab culture from fistula of the lateral part of upper eyelid showed Burkholderia pseudomallei. He was treated with high dose of intravenous ceftazidime, oral cotrimoxazole for the acute management and on maintenance dose of oral cotrimoxazole for 2 months. He responded well to treatment and had no relapse up to one year post treatment. Unfortunately his left eye vision was not salvageable.CONCLUSION: This case illustrates a rare presentation of orbital abscess due to melioidosis which was complicated with cerebral abscess and septicemia. An accurate diagnosis was essential and high dose of susceptible antibiotics was important for the institution of therapy to successfully treat this potentially fatal condition.
KEYWORDS: melioidosis; orbital abscess; cerebral abscess; high dose parenteral ceftazidime
INTRODUCTION
Melioidosis is caused by Burkholderia peudomallei, formerly known as Pseudomonas pseudomallei, a kind of gramnegative bacilli[1]. It is endemic in Southeast Asia and Northern Australia. It has a variable form of presentation, from mild to potentially fatal infections[14].
The commonest presentation is pneumonia with or without septicemia but other presentation can involve soft tissue, bone, joint, genitourinary system, CNS, facial or ocular infections[14]. However, melioidosis presented with orbital abscess was very rarely reported[5,6].
Melioidosis poses a therapeutic challenge to the managing physicians. Inadequate management can cause deterioration of condition, and even carry mortality. In this case, we described a patient who presented with orbital abscess with temporal lobe extension due to melioidosis. He was treated with high dose antibiotics on a prolonged regime in the acute phase followed by a lower dose maintenance therapy for the eradication of the organism.
CASE REPORT
A 55yearold Malay gentleman was newly diagnosed with diabetes mellitus during admission, presented with history of prolonged low grade fever for three weeks and left eye proptosis for five days. Initially, his left eye vision was noted to be mildly impaired. Urgent CT scan of the orbit and brain showed features of left periorbital cellulitis which was confined to the intraconal region. He developed septicemia while being admitted which was supported by the blood culture results which grew Pseudomonas sp. Patient was treated with intravenous ceftazidime 1mg twice per day, cloxacillin 500mg four times a day and metronidazole 500mg three times per day for 2 weeks. His general condition and orbital proptosis improved.
However, upon completion of the intravenous antibiotics, his general condition deteriorated and the left eye became more proptosed . Repeat CT scan of orbit and brain showed features of periorbital cellulitis with small abscesses involving the intra and extraconal areas with extension to the left temporal lobe. MRI of brain and orbit was subsequently done, which showed similar findings (Figure 1). There was no evidence of cavenous sinus thrombosis on magnetic resonance angiography (MRA) sequences (Figure 1). In our hospital, Burkholderia pseudomallei was isolated from a swab at the fistula of the upper eyelid, which was sensitive to ceftazidime and ciprofloxacin and resistant to gentamicin. Serology test also showed presence of immunoglobulin G for Burkholderia pseudomallei. Intravenous high dose parenteral ceftazidime 2mg three times per day with oral cotrimoxazole 650mg twice per day were then started for two months.
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