Recurrent Orbital Abscesses In An Immunocompromised Patient

A man in his 30s with Hyper-IgE syndrome and long-term corticosteroid therapy presented with a three-day history of right facial pain and swelling following a cracked upper molar. He was diagnosed with a buccal space abscess and underwent incision and drainage with extraction of the affected tooth and placement of an intra-oral drain. Operative findings included copious purulent discharge and necrotic tissue within the buccal space. Intravenous clindamycin was commenced.

There was initial improvement, however his condition rapidly deteriorated with worsening right facial swelling, right eye visual loss (hand movements only), a fixed dilated pupil and complete ophthalmoplegia. The left’s visual acuity was 6/36 from long-standing amblyopia. His WCC was 40 x 10⁹/L and CRP was over 300 mg/L. CT showed intraconal and extraconal orbital abscesses.

An urgent lateral canthotomy was performed under local anaesthetic for orbital compartment syndrome, followed by EUA and orbital washout later that day. An orbital drain was placed and he was transferred to HDU and commenced on high-dose intravenous vancomycin, ceftriaxone and corticosteroids.

Further abscesses developed around the orbit and masticator muscles with worsening proptosis. Imaging showed restricted diffusion in the posterior globe, suggestive of secondary optic nerve ischaemia. Second and third decompressions were performed jointly with maxillofacial and ophthalmology teams. Drainage of pus from the intraconal space and the temporalis fascia was achieved via reopening of the lateral orbital wall.

Antibiotics were escalated to intravenous meropenem.

Cultures grew Streptococcus gallolyticus, Streptococcus constellatus, and Granulicatella adiacens. Further collections developed in in the right buccinator, temporalis, and overlying the maxilla and mandible with the addition of a new focus of infection in the lateral pterygoid. Visual acuity became NPL. Unfortunately, due to systemic decline, the patient passed away shortly after.

This case highlights the severe morbidity that can occur in immunocompromised patients i.e. a cracked tooth leading to loss of vision and subsequent death. This underscores the importance of early recognition, urgent imaging and multidisciplinary collaboration.