Atypical presentations of orbital cellulitis in an 11-year-old boy

Spontaneous acute-onset proptosis accompanied with inflammatory signs in children is commonly caused by orbital cellulitis/abscess; however, the clinician should always be alert to the possibility of other causes such as neoplastic: Orbital rhabdomyosarcoma (RMS), traumatic, and iatrogenic factors. This is a case report of an 11-year-old boy presenting with an acute-onset non-axial proptosis of the left eye without a history of trauma, sinus disease, or systemic infection. Our clinical differential diagnosis included orbital cellulitis and orbital RMS. However, the final diagnosis was orbital cellulitis with abscess. The purpose of the study was to report a case of “cold” orbital abscess that clinically mimics orbital RMS. An 11-year-old boy presented with a 2 weeks history of painless, rapid-onset non-axial proptosis in the left eye. It was associated with periorbital edema, and mild conjunctival hyperemia. There was no preceding or associated history of fever, trauma, upper respiratory tract infection, sinusitis, or immunosuppression. An initial clinical diagnosis of RMS, with orbital cellulitis as a differential diagnosis, was made delaying commencement of antibiotic therapy. Following the drainage of greenish tinged purulent matter growing Staphylococcus aureus on culture, the diagnosis of orbital cellulitis with abscess was made. A broad-spectrum antibiotics and subsequent adjunct anti-inflammatory therapy yielded excellent clinical resolution. The case demonstrates the pitfalls/challenges in differentiating orbital space occupying lesions manifesting with inflammatory features on the basis of clinical findings alone. This is particularly relevant in a busy triage ophthalmic clinic in a low resource environment without easy access to any form of orbital imaging. In addition, the case highlights that green tinged purulent matter can be found in infections from a myriad of organisms aside from the popularly known Pseudomonas aeruginosa.