INSTRUCTIVE CASES
Bilateral Cellulitis of Cheeks in an Infant due to Hemophilus influenzae Julius
Landwirth, M.D.
ANUMBER emphasized F~
NUMBER of recent
a ersli4 have papers’-’ of Hemophilus influenzae etiologic agent in cellulitis occurring the role
as an
in young children. Such infections. can be suspected from the clinical presentation, when an acute febrile illnes in an infant between the ages of six months and two years is accompanied by, or is shortly followed by, a rather characteristic skin lesion most often appearing on the cheek. The affected area varies in size, is indurated and erythematous, with a faint but distinct violaceous discoloration IPerceptible within the lesion. The borders are poorly circumscribed and fade into the surrounding normal tissue, unlike classical erysipelas with its raised edges. When the cheek is affected, the buccal mucosa may be inflamed also. As a rule, blood cultures and aspirates from the lesion 45 are positive for H. influenzae. On reviewing the reports for H. influenzae cellulitis, several instances of multifocal involvement were noted, 1.6 but none of bi‘
lateral cheek involvement, which may be
presentation confusing and thereby delay a
diagnosis.
‘
Case Report This was the first Bridgeport Hospital admission for a nine-month-old infant with a two-day history of fever and painful erythema of both cheeks. The infant’s health had been good heretofore. After a day of fever and irritability, his temperature rose to 104 and inflamed swellings arose on both cheeks
simultaneoulsy. At hospitalization, the lesions extended 3.5 by 5.5 cm on each side. They were indurated, slightly tender, and erythematous with a slight bluish discoloration (Fig. l and 2). The infant seemed otherwise comfortable and not severely ill. On examination, the ears, nose, and throat were
normal, and no lesions were found elsewhere. The white cell count was 28,700, mainly PMI~s. Cultures of nose and throat yielded norrnal flora. Blood cultures were obtained before intravenous oxacillin was started, 150 mg per kg per day. After two doses, the antibiotic was changed to intravenous ampicillin in a dose of 400 mg/kg/day, because of a revised clinical impression that the cellulitis was most probably due to H. influenzae. The next day blood cultures were positive for H, influenzae. The fever subsided in two days and did not recur. The skin lesions were completely resolved in three days. The patient was discharged on the sixth hospital day receiving oral ampicillin, which was continued for four more days.
Discussion is known to cause a variety of serious infections in infants and newborns. It has recently even been implicated as a possible agent in urinary tract infectionS.7 H.
Associate Clinical Professor of Pediatrics, Yale University School of Medicine and Chief, Department of Pediatrics, Bridgeport Hospital, Bridgeport, Conn. 06602
influenzae
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’
FIGS. 1 and 2. These views show the infant’s
two
cheeks
at
the
height of inflammatory cellulitis due
to H.
influenzae,
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The initial apparent response to oxacillin by our patient is similar to that observed in several other reported cases in which treatment was begun with penicillin under the assumption that the cellulitis was of grampositive origin. 2.1 Some data suggest that bactericidal levels penicillin can be achieved against some infections caused by H. in-
References 1.
Rapkin, R. H., and Bautista, G.: Hemophilus influenzae cellulitis. Am. J. Dis. Child. 124: 540, 1972.
2.
Bada, H., and Wright, S. P.: Hemophilus cellulitis. Clin. Pediatr. 658, 13 : 1974.
3.
Feingold, M., and Gellis, S. S.: Cellulitis due to Hemophilus influenzae type B. N. Engl. J. Med.
4.
8
~ue~czcae. ~
The focus of infection of patients with H. influenzae cellulitis is often unclear. There was no evidence of underlying ethmoid sinusitis or orbital cellulitis in our patient; indeed, such infections are rarely bilateral. Controversy exists concerning the level of immunity to H. i~~u~nzae in the population at large and whether the patterns of susceptibility have changed in recent years.9-11 These epidemiologic concerns, the propensity of H, influenzae for rapid hematogenous spread, and current indications of changing sensitivity patterns to antimicrobial agents, 12 all heighten the importance not only of early recognition of infections caused by H. ir~flUenzae, but also of starting appropriate therapy without awaiting laboratory confirmation.
5.
influenzae
272: 788, 1965. Minnefor, A. B., Murray, J. J., and Davis,
P. H.;
Hemophilus cellulitis influenzae of the lower extremity. Am. J. Dis. Child 124: 920, 1972. Goetz, J. P., Tafari, N., and Boxerbaum, B.: Needle aspiration in Hemophilus influenzae type B cellulitis.
Pediatrics 54: 504, 1974. 6. Green, M., and Fousek, M. D.:
Hemophilus influenzae
type B cellulitis. Pediatrics 19: 80, 1957.
Granoff, D. M., and Roskes, S.: Urinary tract infection due to Hemophilus influenzae type B. 84: 414, 1974. J. Pediatr. 8. McLinn, S. E., Nelson, J. D., and Haltalin, K. C.: 7.
Antimicrobial . enzae
9. Smith,
susceptibility of Hemophilus influPediatrics 45: 827, 1970. E. W. P., and Haynes, R. E.: Changing
incidence of Hemophilus influenzae meningitis. Pediatrics 50: 723, 1972. 10. Graber, C. D., Gershank, J. J., Vefkoff, A. H., and Westphal, M.: Changing patterns of neonatal
susceptibility J. Hemophilus influnezae. Pediatrics to 78: 948, 1971.
11.
Norden, C. W.: Prevalence of bactericidal antibodies 130: Hemophilus influenzae B. J. Infect. Dis. to type 489, 1974.
12. Katz, S. L.: Ampicillin-resistant Hemophilus influenzae type B: a status report. Pediatrics 55: 6, 1975.
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