Orbital cellulitis causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2] Tarek Nafee, M.D. [3]

Overview

Common causes of orbital cellulitis are infections with either Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, or beta-hemolytic streptococci.

Causes

Orbital cellulitis occurs most commonly from bacterial infection. In some cases, mycobacteria or fungal organisms may also be implicated.[1][2][3][4] Difficulty arises in identifying a specific organism due to challenges in culturing the retroseptal orbital region. Blood cultures are typically positive in 4% of patients with orbital cellulitis with the highest reported rate of positive result of 31%. Mucosal swabs of nasal and preseptal mucosa show a slightly higher positive culture result of 51%; however, their accuracy is a topic of debate considering the normal flora in these tissues. The most likely source of a positive culture in confirmed orbital cellulitis patients is a surgical specimen from an abscess or nasal sinus aspirate. This procedure is not routinely performed on all patients with orbital cellulitis, thus this represents a subsection of the population.[5]

Cause by Pathogen

The most commonly reported pathogens, regardless of culturing method were Staphylococcus aureus, Streptococcus spp., and Haemophilus influenza. With the rise of microbial resistance in more recent years, Methicillian-Resistant Staphylococcus Aureus (MRSA) must be considered as a potential cause and correlated with geographic prevalence. MRSA has been cultured in as high as 73% of cases in a retrospective study of orbital cellulitis patients. Alternatively, with the dissemination of *Haemophilus influenza type b (Hib)* vaccine, the incidence of *Haemophilus spp.* caused orbital cellulitis has decreased significantly.[1][2] It has also been reported that in patients above the age of 15-16, cultures are more likely to grow a mixed, polymicrobial flora with both aerobic and anaerobic bacteria.[3]

It is important to note that, although rare, in immunocompromised patients we begin to see an increase in incidence of fungal and mycobacterial sources of infections. The most common fungal infections encountered in this population were Mucormycosis and Aspergilliosis. Mycobacterium tuberculosis has also been reported in immunocompromised patients in endemic regions.[2]

Cause by Etiology

Another effective way to categorize the causes of orbital cellulitis is according to the underlying etiology or source of infection. By far, the most common underlying condition is ethmoid sinusitis. It has been reported as the cause in 90-98% of orbital cellulitis cases.[1][6][7] Though some causes of orbital cellulitis may be uncommon, it is pertinent to consider all possible etiologies and associated conditions' most common pathogens according to the clinical scenario:[2][5]

  • Sinusitis: Staphylococcus aureus, Streptococcus spp., H. influenza
  • Dacryocystitis, dacryoadenitis, and other lacrimal duct abnormalities: Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenza
  • Traumatic/Foreign body: Staphyloccus aureus, Streptococcus epidermidis, Enterococcus spp., Escherichia coli, Eikenella spp.
  • Spread from superficial infections of the face or adjacent soft tissue: Staphylococcus aureus, Streptococcus pyogenes
  • Dental caries/abscess: Bacteroides spp. anaerobes, and gram negative rods
  • Iatrogenic/post-surgical procedures: Staphylococcus aureus, Streptococcus spp.
  • Immunocompromised patient: Mucormycosis, Aspergilliosis, M.Tuberculosis
  • Diabetic patients with or without history of diabetic ketoacidosis: Pseudomonas aeruginosa, Klebsiella pneumoniae

Cause by Organ System

Cardiovascular No underlying causes
Chemical/Poisoning No underlying causes
Dental Dental infection, tooth abscess
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat Ethmoid sinusitis, otitis media, sinusitis
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic Peribulbar anesthesia, surgical trauma
Infectious Disease Aeromonas hydrophila, anaerobes, arcanobacterium, aspergillosis, aspergillus, bacterial rhinosinusitis, bacteroides, beta-hemolytic streptococci, dacryocystitis, dental infection, eikenella corrodens, enterococcus, ethmoid sinusitis, haemophilus influenzae, haemophilus parainfluenzae, infected mucocele, klebsiella pneumoniae, moraxella catarrhalis, MRSA, MSSA, mucor, mucorales, mucormycosis, mycobacterium tuberculosis, neisseria gonorrhea, osteomyelitis of the orbital bones, otitis media, peptostreptococcus, pseudomonas aeruginosa, rothia mucilaginosa, sinusitis, staphylococcus aureus, streptococcus anginosus, streptococcus milleri, streptococcus pneumoniae, streptococcus pyogenes, streptococcus, tooth abscess, varicella
Musculoskeletal/Orthopedic No underlying causes
Neurologic No underlying causes
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Ophthalmologic Blepharoplasty, dacryocystitis, dacryocystorhinostomy, eyelid surgery, ophthalmic surgery, orbital decompression, orbital fracture, osteomyelitis of the orbital bones, radial keratotomy, retinal surgery, strabismus surgery
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary Mycobacterium tuberculosis
Renal/Electrolyte No underlying causes
Rheumatology/Immunology/Allergy No underlying causes
Sexual No underlying causes
Trauma Orbital fracture, trauma
Urologic No underlying causes
Miscellaneous Foreign body, phlebitis of the facial veins


Causes in Alphabetical Order

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References

  1. 1.0 1.1 1.2 Hasanee K, Sharma S (2004). "Ophthaproblem. Orbital cellulitis". Can Fam Physician. 50: 359, 365, 367. PMC 2214559. PMID 15318671.
  2. 2.0 2.1 2.2 2.3 Lam Choi VB, Yuen HK, Biswas J, Yanoff M (2011). "Update in pathological diagnosis of orbital infections and inflammations". Middle East Afr J Ophthalmol. 18 (4): 268–76. doi:10.4103/0974-9233.90127. PMC 3249811. PMID 22224014.
  3. 3.0 3.1 Merck Manual Professional Version (2016)https://www.merckmanuals.com/professional/eye-disorders/orbital-diseases/preseptal-and-orbital-cellulitis
  4. American Academy of Ophthalmology Eyewiki (2015)http://eyewiki.aao.org/Orbital_Cellulitis#Etiology
  5. 5.0 5.1 Baring DE, Hilmi OJ (2011). "An evidence based review of periorbital cellulitis". Clin Otolaryngol. 36 (1): 57–64. doi:10.1111/j.1749-4486.2011.02258.x. PMID 21232022.
  6. Nageswaran S, Woods CR, Benjamin DK, Givner LB, Shetty AK (2006). "Orbital cellulitis in children". Pediatr Infect Dis J. 25 (8): 695–9. doi:10.1097/01.inf.0000227820.36036.f1. PMID 16874168.
  7. Chaudhry IA, Al-Rashed W, Arat YO (2012). "The hot orbit: orbital cellulitis". Middle East Afr J Ophthalmol. 19 (1): 34–42. doi:10.4103/0974-9233.92114. PMC 3277022. PMID 22346113.

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