Previously healthy but elderly male that wears glasses (no contacts), without significant surgical history presents with sudden progressively worsening left eye swelling, erythema, and conjunctival discharge over the past 26 hours. Denies any recent trauma or eye drop use.

Initial Vitals:

SpO2 97 on room air

HR 110

RR 19

BP 110/60

T 38.8˚C

ED Evalaution

Physical exam was remarkable for severe left periorbital swelling with erythema and some skin whitening, developing bullae and worsening pain on palpation, hemorrhagic chemosis with purulent drainage from his left eye, and slight purulent drainage to the right eye.

Labs show leukocytosis to 15000 with 24% bands, CRP 233, Procalcitonin of 24, lactic of 1.5.

CT remarkable for: Periorbital cellulitis with extension

Out of concern for necrotizing fasciitis, ophthalmology and facial surgery were consulted

Patient Course

The patient was emergently brought to the OR for debridement with ophthalmology and facial surgery after being treated for sepsis and double covered with vancomycin, Ampicillin/Sulbactam and clindamycin.

A wound culture eventually grew: Streptococcus pyogenes

After a prolonged in patient hospitalization, patient was discharged home on oral antibiotics with intact vision and follow up arranged

Periorbital Necrotizing Fascitis!

A Zebra Diagnosis

A rapidly progressing infection
Usually, but not always preceded by trauma (penetrating or surgical)
Oftentimes caused by Group A beta hemolytic Streptococcus
Diagnosis is clinical, associated with erythematous and sometimes pale skin with associated swelling, crepitus with pain and fever
Treatment is with antibiotics and sometimes surgical debridement
Mortality is 8.5-10%