Research
Brief Report
Methicillin-Resistant Staphylococcus aureus Dacryoadenitis Wenjing Liu, MD; Daniel B. Rootman, MD, MSc; Jesse L. Berry, MD; Catherine J. Hwang, MD; Robert A. Goldberg, MD
IMPORTANCE Although classically thought to be primarily a nosocomial infection, the
incidence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is rising. In this series we report 3 cases of community-acquired MRSA acute dacryoadenitis in adults presenting within a 3-week period. OBSERVATIONS All cases presented with pain and periocular erythema increasing over approximately 1 week. An S-shaped lid deformity was evident, and 2 of the 3 cases demonstrated multiple pustules/abscesses in the region of the lacrimal gland that were expressing purulent fluid into the superior fornix. Eye cultures yielded MRSA. Each case had complete clinical resolution with 2 to 4 days of intravenous vancomycin followed by 1 week of oral trimethoprim-sulfamethoxazole combination therapy. CONCLUSIONS AND RELEVANCE These cases underscore the changing profile of MRSA infections, especially in the community-based setting. MRSA dacryoadenitis can be difficult to treat with standard therapeutic approaches and may progress to orbital cellulitis. We recommend a short admission for intravenous antibiotic therapy while bacterial sensitivities are being determined before transitioning to a dual-targeted oral antibiotic regimen. JAMA Ophthalmol. 2014;132(8):993-995. doi:10.1001/jamaophthalmol.2014.965 Published online May 29, 2014.
A
cute dacryoadenitis is characterized by inflammation and enlargement of the lacrimal gland that leads to swelling of the lateral eyelid, tenderness over the lacrimal gland fossa, and injection over the palpebral lobe of the lacrimal gland. A relatively rare entity, acute infectious dacryoadenitis occurs in approximately 1 of 10 000 ophthalmic outpatients.1 Acute suppurative bacterial dacryoadenitis is even more rare. In the largest case series to date, cultures from 6 of the 11 patients yielded Staphylococcus aureus; however, none was reported to be methicillin-resistant.2 Although classically thought to be a nosocomial infection, the incidence of community-acquired methicillinresistant S aureus (MRSA) is rising.3 MRSA as a cause of bacterial dacryoadenitis has been previously reported in only a single case study4 and in 5 pediatric cases as part of a series on orbital cellulitis.5 In this article, we present 3 cases of MRSA dacryoadenitis in adults presenting within a 3-week period and discuss the presentation, course, and treatment of this entity. This case series complied with the Health Insurance Portability and Accountability Act privacy rules.
Report of Cases
Author Affiliations: Division of Orbital and Oculoplastic Surgery, Jules Stein Eye Institute, University of California, Los Angeles (Liu, Rootman, Hwang, Goldberg); Department of Ophthalmology, Children’s Hospital, Los Angeles, California (Berry). Corresponding Author: Wenjing Liu, MD, Division of Orbital and Oculoplastic Surgery, Jules Stein Eye Institute, University of California, l Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095 ([email protected]).
which an unknown topical antibiotic drop was ineffective. A week earlier, she had myalgias and fatigue that she had attributed to influenza. On examination, her visual acuity was 20/20 OD with limitation on abduction and associated pain. The right upper eyelid was edematous and erythematous with an S-shaped deformity (Figure 1). She had purulent discharge in the right upper cul-de-sac and pustules in the lateral fornix, which were cultured. Computed tomographic imaging was notable for inflammation of the right periorbital soft tissues, with enhancement of the lacrimal gland and associated internal abscesses (Figure 2). The patient was diagnosed as having right dacryoadenitis and associated preseptal cellulitis. She began treatment with intravenous (IV) vancomycin and a combination of piperacillin sodium and tazobactam sodium. After 4 days of improvement while receiving IV antibiotics, culture results returned as positive for MRSA. The patient’s treatment was switched from IV antibiotics to a 10-day course of trimethoprim-sulfamethoxazole and cephalexin. At the time of discharge, the upper eyelid erythema and edema were improved with no more purulent drainage. At follow-up 2 weeks later, the infection had resolved.
Case 1
Case 2
An African American woman in her 40s presented with a 4-day history of redness and swelling of her right upper eyelid for
A Hispanic woman in her 20s presented with 1 week of pain, swelling, and redness around her right eye soon after having
jamaophthalmology.com
JAMA Ophthalmology August 2014 Volume 132, Number 8
Copyright 2014 American Medical Association. All rights reserved.
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993
Research Brief Report
MRSA Dacryoadenitis
her eyebrows waxed. She was diagnosed as having preseptal cellulitis and was treated with oral cephalexin and an unknown antibiotic ointment without improvement. On transfer to our department, her visual acuity was 20/50 OD with a trace relative afferent pupillary defect. She demonstrated limitation in abduction with associated pain. She had extensive periorbital erythema and edema of the right upper eyelid with purulent drainage originating under the lateral as-
Figure 1. Clinical Photograph of Patient 1
pect, which was cultured. She began treatment with IV vancomycin and ceftriaxone sodium. A computed tomographic scan of the orbits showed preseptal swelling with postseptal fat stranding and a periorbital abscess in the region of the lacrimal gland. The patient improved clinically during 2 days of IV antibiotic treatment, with almost complete resolution of the periorbital swelling and recovery of abduction of the right eye. Culture results returned as positive for MRSA, and the patient was discharged on trimethoprim-sulfamethoxazole. At follow-up 1 week later, the patient’s symptoms had resolved.
Case 3
Right upper eyelid edema with associated S-shaped deformity and copious purulent discharge is apparent.
A white man in his 40s presented with left upper eyelid swelling and blurry vision in the left eye. He had first noticed a “stye” on his left upper eyelid 8 days previously, and his left eye became inflamed with purulent discharge. At the emergency department the discharge was cultured, and the results were positive for gram-positive cocci; he was discharged with bacitracin ointment as treatment. Of note, the patient’s wife had had 2 recent MRSA infections. On examination, his visual acuity was 20/25 OS, and abduction was mildly limited with associated pain. He had hyperemia and chemosis of the conjunctiva, with purulent drainage from the superolateral fornix of the left eye. The palpebral lobe of the left lacrimal gland was enlarged. The patient was diagnosed as having left dacryoadenitis and associated orbital cellulitis. The patient began treatment with IV vancomycin and a combination of ampicillin sodium and sulbactam sodium. A computed tomographic scan of the orbits demonstrated preseptal cellulitis and enhancing lacrimal gland. The culture results returned as positive for MRSA. The patient’s symptoms improved after 2 days of IV antibiotics, and he was dis-
Figure 2. Computed Tomography (CT) With Contrast in Patient 1 A
B
A, Coronal view. B, Axial view. Enlargement and enhancement of the lacrimal gland with focal abscesses (arrowheads) is shown.
994
JAMA Ophthalmology August 2014 Volume 132, Number 8
Copyright 2014 American Medical Association. All rights reserved.
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jamaophthalmology.com
MRSA Dacryoadenitis
Brief Report Research
charged while receiving treatment with oral doxycycline hyclate and trimethoprim-sulfamethoxazole combination therapy. At follow-up 1 week later, the patient’s symptoms had resolved.
Box. Sensitivities From Staphylococcus aureus Culturesa Resistant
Oxacillin (1-3)/penicillin (1-3) Ciprofloxacin (1, 3)/levofloxacin (2) Erythromycin (1, 2)
Discussion
Cefazolin (3)
During the past decade, MRSA has become an increasingly prevalent cause of skin and soft-tissue infections.3 The increase in prevalence can be partially attributed to the increase in community-acquired MRSA in individuals without recent exposure to the health care environment or other risk factors. As a result of the rising prevalence and challenges in treatment, a high index of suspicion must be maintained for MRSA infections. In the cases described, previously healthy adults presented with symptoms of acute dacryoadenitis that were unresponsive to antibiotic eyedrops, ointment, or standard oral therapy. All patients described a preceding event and, in 4 to 8 days, they exhibited progressive orbital signs of infection. In each case, a draining pus cavity was identified and served as a source for culture. All 3 cases were initially treated with broad-spectrum IV antibiotics including vancomycin. After sensitivities became available (Box), the patients’ treatment was transitioned to focused oral regimens. Symptomatic improvement occurred in 2 to 4 days, and it was not necessary to drain any abscess in the lacrimal gland. These cases underscore the changing profile of MRSA infections. Such community-acquired infections are often treated as viral with supportive care or as typical bacterial preseptal
ARTICLE INFORMATION Published Online: May 29, 2014. doi:10.1001/jamaophthalmol.2014.965. Author Contributions: Drs Rootman and Berry had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Liu, Rootman, Hwang, Goldberg. Acquisition, analysis, or interpretation of data: Liu, Berry. Drafting of the manuscript: Liu. Critical revision of the manuscript for important intellectual content: All authors.
Sensitive
Trimethoprim/sulfamethoxazole (1-3) Rifampin (1-3) Doxycycline (1, 3)/tetracycline (2)/tigecycline (2) Vancomycin (1, 2) Clindamycin (1, 2) Linezolid (2) Gentamicin (3) a
Numbers in parentheses denote the case numbers that exhibited the corresponding antibiotic sensitivity.
cellulitis with beta-lactam antibiotics. MRSA dacryoadenitis can be difficult to treat with standard therapeutic approaches and may progress to orbital cellulitis. The presence of a draining abscess or worsening of symptoms should prompt further investigation for MRSA. We recommend a short admission for IV antibiotic therapy in cases of suppurative bacterial dacryoadenitis with associated lacrimal gland abscess and surrounding fat stranding, before transitioning treatment to a dual-targeted oral antibiotic regimen.
Statistical analysis: Rootman. Administrative, technical, or material support: Liu. Study supervision: Rootman, Berry, Hwang, Goldberg. Conflict of Interest Disclosures: None reported. REFERENCES 1. Rhem MN, Wilhelmus KR, Jones DB. Epstein-Barr virus dacryoadenitis. Am J Ophthalmol. 2000;129 (3):372-375. 2. Goold LA, Madge SN, Au A, et al. Acute suppurative bacterial dacryoadenitis: a case series. Br J Ophthalmol. 2013;97(6):735-738.
jamaophthalmology.com
3. Moran GJ, Krishnadasan A, Gorwitz RJ, et al; Emergency ID Net Study Group. Methicillinresistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355 (7):666-674. 4. Kubal A, Garibaldi DC. Dacryoadenitis caused by methicillin-resistant Staphylococcus aureus. Ophthal Plast Reconstr Surg. 2008;24(1):50-51. 5. Mathias MT, Horsley MB, Mawn LA, et al. Atypical presentations of orbital cellulitis caused by methicillin-resistant Staphylococcus aureus. Ophthalmology. 2012;119(6):1238-1243.
JAMA Ophthalmology August 2014 Volume 132, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/01/2015
995
Brief Report
Methicillin-Resistant Staphylococcus aureus Dacryoadenitis Wenjing Liu, MD; Daniel B. Rootman, MD, MSc; Jesse L. Berry, MD; Catherine J. Hwang, MD; Robert A. Goldberg, MD
IMPORTANCE Although classically thought to be primarily a nosocomial infection, the
incidence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is rising. In this series we report 3 cases of community-acquired MRSA acute dacryoadenitis in adults presenting within a 3-week period. OBSERVATIONS All cases presented with pain and periocular erythema increasing over approximately 1 week. An S-shaped lid deformity was evident, and 2 of the 3 cases demonstrated multiple pustules/abscesses in the region of the lacrimal gland that were expressing purulent fluid into the superior fornix. Eye cultures yielded MRSA. Each case had complete clinical resolution with 2 to 4 days of intravenous vancomycin followed by 1 week of oral trimethoprim-sulfamethoxazole combination therapy. CONCLUSIONS AND RELEVANCE These cases underscore the changing profile of MRSA infections, especially in the community-based setting. MRSA dacryoadenitis can be difficult to treat with standard therapeutic approaches and may progress to orbital cellulitis. We recommend a short admission for intravenous antibiotic therapy while bacterial sensitivities are being determined before transitioning to a dual-targeted oral antibiotic regimen. JAMA Ophthalmol. 2014;132(8):993-995. doi:10.1001/jamaophthalmol.2014.965 Published online May 29, 2014.
A
cute dacryoadenitis is characterized by inflammation and enlargement of the lacrimal gland that leads to swelling of the lateral eyelid, tenderness over the lacrimal gland fossa, and injection over the palpebral lobe of the lacrimal gland. A relatively rare entity, acute infectious dacryoadenitis occurs in approximately 1 of 10 000 ophthalmic outpatients.1 Acute suppurative bacterial dacryoadenitis is even more rare. In the largest case series to date, cultures from 6 of the 11 patients yielded Staphylococcus aureus; however, none was reported to be methicillin-resistant.2 Although classically thought to be a nosocomial infection, the incidence of community-acquired methicillinresistant S aureus (MRSA) is rising.3 MRSA as a cause of bacterial dacryoadenitis has been previously reported in only a single case study4 and in 5 pediatric cases as part of a series on orbital cellulitis.5 In this article, we present 3 cases of MRSA dacryoadenitis in adults presenting within a 3-week period and discuss the presentation, course, and treatment of this entity. This case series complied with the Health Insurance Portability and Accountability Act privacy rules.
Report of Cases
Author Affiliations: Division of Orbital and Oculoplastic Surgery, Jules Stein Eye Institute, University of California, Los Angeles (Liu, Rootman, Hwang, Goldberg); Department of Ophthalmology, Children’s Hospital, Los Angeles, California (Berry). Corresponding Author: Wenjing Liu, MD, Division of Orbital and Oculoplastic Surgery, Jules Stein Eye Institute, University of California, l Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095 ([email protected]).
which an unknown topical antibiotic drop was ineffective. A week earlier, she had myalgias and fatigue that she had attributed to influenza. On examination, her visual acuity was 20/20 OD with limitation on abduction and associated pain. The right upper eyelid was edematous and erythematous with an S-shaped deformity (Figure 1). She had purulent discharge in the right upper cul-de-sac and pustules in the lateral fornix, which were cultured. Computed tomographic imaging was notable for inflammation of the right periorbital soft tissues, with enhancement of the lacrimal gland and associated internal abscesses (Figure 2). The patient was diagnosed as having right dacryoadenitis and associated preseptal cellulitis. She began treatment with intravenous (IV) vancomycin and a combination of piperacillin sodium and tazobactam sodium. After 4 days of improvement while receiving IV antibiotics, culture results returned as positive for MRSA. The patient’s treatment was switched from IV antibiotics to a 10-day course of trimethoprim-sulfamethoxazole and cephalexin. At the time of discharge, the upper eyelid erythema and edema were improved with no more purulent drainage. At follow-up 2 weeks later, the infection had resolved.
Case 1
Case 2
An African American woman in her 40s presented with a 4-day history of redness and swelling of her right upper eyelid for
A Hispanic woman in her 20s presented with 1 week of pain, swelling, and redness around her right eye soon after having
jamaophthalmology.com
JAMA Ophthalmology August 2014 Volume 132, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/01/2015
993
Research Brief Report
MRSA Dacryoadenitis
her eyebrows waxed. She was diagnosed as having preseptal cellulitis and was treated with oral cephalexin and an unknown antibiotic ointment without improvement. On transfer to our department, her visual acuity was 20/50 OD with a trace relative afferent pupillary defect. She demonstrated limitation in abduction with associated pain. She had extensive periorbital erythema and edema of the right upper eyelid with purulent drainage originating under the lateral as-
Figure 1. Clinical Photograph of Patient 1
pect, which was cultured. She began treatment with IV vancomycin and ceftriaxone sodium. A computed tomographic scan of the orbits showed preseptal swelling with postseptal fat stranding and a periorbital abscess in the region of the lacrimal gland. The patient improved clinically during 2 days of IV antibiotic treatment, with almost complete resolution of the periorbital swelling and recovery of abduction of the right eye. Culture results returned as positive for MRSA, and the patient was discharged on trimethoprim-sulfamethoxazole. At follow-up 1 week later, the patient’s symptoms had resolved.
Case 3
Right upper eyelid edema with associated S-shaped deformity and copious purulent discharge is apparent.
A white man in his 40s presented with left upper eyelid swelling and blurry vision in the left eye. He had first noticed a “stye” on his left upper eyelid 8 days previously, and his left eye became inflamed with purulent discharge. At the emergency department the discharge was cultured, and the results were positive for gram-positive cocci; he was discharged with bacitracin ointment as treatment. Of note, the patient’s wife had had 2 recent MRSA infections. On examination, his visual acuity was 20/25 OS, and abduction was mildly limited with associated pain. He had hyperemia and chemosis of the conjunctiva, with purulent drainage from the superolateral fornix of the left eye. The palpebral lobe of the left lacrimal gland was enlarged. The patient was diagnosed as having left dacryoadenitis and associated orbital cellulitis. The patient began treatment with IV vancomycin and a combination of ampicillin sodium and sulbactam sodium. A computed tomographic scan of the orbits demonstrated preseptal cellulitis and enhancing lacrimal gland. The culture results returned as positive for MRSA. The patient’s symptoms improved after 2 days of IV antibiotics, and he was dis-
Figure 2. Computed Tomography (CT) With Contrast in Patient 1 A
B
A, Coronal view. B, Axial view. Enlargement and enhancement of the lacrimal gland with focal abscesses (arrowheads) is shown.
994
JAMA Ophthalmology August 2014 Volume 132, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/01/2015
jamaophthalmology.com
MRSA Dacryoadenitis
Brief Report Research
charged while receiving treatment with oral doxycycline hyclate and trimethoprim-sulfamethoxazole combination therapy. At follow-up 1 week later, the patient’s symptoms had resolved.
Box. Sensitivities From Staphylococcus aureus Culturesa Resistant
Oxacillin (1-3)/penicillin (1-3) Ciprofloxacin (1, 3)/levofloxacin (2) Erythromycin (1, 2)
Discussion
Cefazolin (3)
During the past decade, MRSA has become an increasingly prevalent cause of skin and soft-tissue infections.3 The increase in prevalence can be partially attributed to the increase in community-acquired MRSA in individuals without recent exposure to the health care environment or other risk factors. As a result of the rising prevalence and challenges in treatment, a high index of suspicion must be maintained for MRSA infections. In the cases described, previously healthy adults presented with symptoms of acute dacryoadenitis that were unresponsive to antibiotic eyedrops, ointment, or standard oral therapy. All patients described a preceding event and, in 4 to 8 days, they exhibited progressive orbital signs of infection. In each case, a draining pus cavity was identified and served as a source for culture. All 3 cases were initially treated with broad-spectrum IV antibiotics including vancomycin. After sensitivities became available (Box), the patients’ treatment was transitioned to focused oral regimens. Symptomatic improvement occurred in 2 to 4 days, and it was not necessary to drain any abscess in the lacrimal gland. These cases underscore the changing profile of MRSA infections. Such community-acquired infections are often treated as viral with supportive care or as typical bacterial preseptal
ARTICLE INFORMATION Published Online: May 29, 2014. doi:10.1001/jamaophthalmol.2014.965. Author Contributions: Drs Rootman and Berry had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Liu, Rootman, Hwang, Goldberg. Acquisition, analysis, or interpretation of data: Liu, Berry. Drafting of the manuscript: Liu. Critical revision of the manuscript for important intellectual content: All authors.
Sensitive
Trimethoprim/sulfamethoxazole (1-3) Rifampin (1-3) Doxycycline (1, 3)/tetracycline (2)/tigecycline (2) Vancomycin (1, 2) Clindamycin (1, 2) Linezolid (2) Gentamicin (3) a
Numbers in parentheses denote the case numbers that exhibited the corresponding antibiotic sensitivity.
cellulitis with beta-lactam antibiotics. MRSA dacryoadenitis can be difficult to treat with standard therapeutic approaches and may progress to orbital cellulitis. The presence of a draining abscess or worsening of symptoms should prompt further investigation for MRSA. We recommend a short admission for IV antibiotic therapy in cases of suppurative bacterial dacryoadenitis with associated lacrimal gland abscess and surrounding fat stranding, before transitioning treatment to a dual-targeted oral antibiotic regimen.
Statistical analysis: Rootman. Administrative, technical, or material support: Liu. Study supervision: Rootman, Berry, Hwang, Goldberg. Conflict of Interest Disclosures: None reported. REFERENCES 1. Rhem MN, Wilhelmus KR, Jones DB. Epstein-Barr virus dacryoadenitis. Am J Ophthalmol. 2000;129 (3):372-375. 2. Goold LA, Madge SN, Au A, et al. Acute suppurative bacterial dacryoadenitis: a case series. Br J Ophthalmol. 2013;97(6):735-738.
jamaophthalmology.com
3. Moran GJ, Krishnadasan A, Gorwitz RJ, et al; Emergency ID Net Study Group. Methicillinresistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355 (7):666-674. 4. Kubal A, Garibaldi DC. Dacryoadenitis caused by methicillin-resistant Staphylococcus aureus. Ophthal Plast Reconstr Surg. 2008;24(1):50-51. 5. Mathias MT, Horsley MB, Mawn LA, et al. Atypical presentations of orbital cellulitis caused by methicillin-resistant Staphylococcus aureus. Ophthalmology. 2012;119(6):1238-1243.
JAMA Ophthalmology August 2014 Volume 132, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/01/2015
995
