From Viral Conjunctivitis To Scleral Emphysema: A Rare Complication In An Immunocompromised Adolescent

To report a rare case of secondary bacterial orbital infection with scleral emphysema following adenoviral conjunctivitis in an immunocompromised adolescent post–bone marrow transplantation. The case highlights an unusual progression from viral conjunctivitis with pseudomembrane formation to corneal ulcer to preseptal cellulitis to orbital cellulitis and intra-scleral air accumulation associated with acute pupillary dysfunction and visual reduction, and how it was systemically managed medicaly and locally managed with a amniotic membrane use.

Tertiary care hospital in Dubai, United Arab Emirates. The patient was co-managed by ophthalmology, pediatrician and  infectious disease, and hematology teams due to her immunocompromised status following bone marrow transplantation.

A 15-year-old female with a history of bone marrow transplantation was admitted for fever and developed unilateral eyelid swelling. Ophthalmic examination revealed severe adenoviral conjunctivitis with pseudomembrane formation, which was treated with membrane peeling, topical steroids, and supportive therapy. Two days later, she developed worsening eyelid edema consistent with preseptal cellulitis and was started on systemic antibiotics. Within 24 hours, she presented with sudden fixed dilated pupil in the affected eye without pain and conjunctival chemosis and a large corneal ulcer.

Urgent MRI demonstrated scleral emphysema with multiple air pockets localized to the sclera near the ciliary body. Blood cultures and ocular samples grew methicillin-resistant Staphylococcus aureus and gram-negative organisms. The patient was admitted and treated with intensive intravenous antimicrobial therapy, and topical medical treatment, Clinical improvement was observed after four days with resolution of eyelid swelling, stabilization of vision, and gradual recovery of pupillary function but a persistent non healing corneal ulcer which was managed by tooical PF medications and application of ambiodisc amniotic grafts until proper healing occured.

This case illustrates a rare and sight-threatening progression of adenoviral conjunctivitis in an immunocompromised patient, complicated by secondary bacterial infection leading to preseptal cellulitis and scleral emphysema. Sudden pupillary changes and visual decline should prompt urgent imaging to exclude deeper orbital or scleral involvement. Early multidisciplinary management and aggressive antimicrobial therapy are critical. Clinicians should maintain high suspicion for atypical complications of common viral infections in post–bone marrow transplant patients.