Orbit, 26:4748, 2007

c 2007 Informa Healthcare

Copyright

ISSN: 0167-6830
DOI: 10.1080/01676830600666185

CASE REPORT

Necrotizing Pseudomonas
Blepharoconjunctivitis
Edward H. Hughes
Department of ophthalmology,
Princess Royal University
Hospital, Farnborough,
Kent, UK
Riaz I. Ahmed
Department of paediatrics,
Princess Royal University
Hospital, Farnborough,
Kent, UK
Christopher J. Hammond
Department of ophthalmology,
Princess Royal University
Hospital, Farnborough,
Kent, UK

Received 1 August 2005;

Accepted 15 October 2005.
Address correspondence to Mr E. H.
Hughes, Sussex Eye Hospital, Eastern
Road, Brighton BN2 5BF, UK. E-mail:
edward.hughes@bsuh.nhs.uk

KEYWORDS Pseudomonas aeruginosa; necrotizing blepharoconjunctivitis; neutropenia;

infant

INTRODUCTION
Necrotizing Pseudomonas blepharoconjuctivitis is an extremely rare condition
with potentially severe complications and resistance to treatment with many
antibacterials used for pre-septal cellulitis. We describe a case of a 20-month-old
female infant with a necrotizing eyelid infection caused by P. aeruginosa.

CASE REPORT
A 20-month-old girl was admitted to hospital with a 3-day history of a sticky
right eye with progressive eyelid swelling. She was previously well but on the day
of admission was listless and pyrexial (39.9 C). Examination revealed erythema
and swelling of the right lower eyelid, mild conjunctival injection and a clear
cornea. Ocular movements were full and there was no proptosis. A diagnosis of
pre-septal cellulitis was made, conjunctival swabs were taken and she was commenced on topical chloramphenicol and a second generation cephalosporin
antibiotic intravenously. This was changed after one dose to piptazobactam
and gentamicin in line with a febrile neutropenia protocol when the result
of her full blood count revealed a leukocyte count of 22.3 109 /L with 73%
lymphoblasts. She was anaemic (Hb 8.2 g/dl), thrombocytopenic (platelets
34 109 /L) and neutropenic (0.7 109 /L). A provisional diagnosis of acute
lymphoblastic leukaemia was made and was later confirmed by a bone marrow
biopsy to be the common type.
The following day her pyrexia had improved and the lid swelling was unchanged, but there was some dark discolouration of the medial right lower lid
margin. Blood cultures were negative but conjunctival swab cultures had a heavy
growth of Pseudomonas aeruginosa resistant to second generation cephalosporins
but sensitive to ciprofloxacin and gentamicin. Ofloxacin drops were applied two
hourly and steady clinical improvement ensued, but the medial lower lid margin
became ulcerated and excavated, without eschar or devitalised tissue (Fig. 1).
Intravenous gentamicin was continued for two weeks and she was commenced on vincristine and dexamethasone according to the UKALL 2003
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FIGURE 1 Photograph taken three days after commencing intravenous antibiotics showing mild residual swelling of the right
lower eyelid. An ulcerated notch deformity is seen medially involving the lacrimal punctum and there is loss of eyelashes from the
entire medial half of the lower lid.

protocol for first phase remission induction. The ulcerated area healed with conservative management leaving
a notch and at no point was the cornea involved.

DISCUSSION
Necrotizing
blepharoconjunctivitis
due
to
Pseudomonas aeruginosa infection is an extremely
rare but potentially devastating complication of a
compromised immune status. This Gram-negative rod
is a common ocular pathogen found in microbial
keratitis (Varaprasathan et al., 2004) (often secondary
to contact lens wear), in outbreaks of conjunctivitis on
neonatal intensive care units (Shah & Gallagher, 1998),
and may occasionally cause infection in the presence
of a foreign body (e.g. scleral buckle (Chaudhry et al.,
1998)), as well as infections at other sites including
the skin and lower respiratory tract. Certain strains of
the bacterium are known to produce a range of lytic
enzymes, including elastase and proteases (Morihara
& Tsuzuki, 1977), which enhance its invasiveness,
and although healthy humans are highly resistant to
invasion by Pseudomonas aeruginosa at vascularised
sites, infection of the avascular cornea may result in
perforation and profound visual consequences. Invasive infection of the conjunctiva and eyelid probably
requires significant immune compromise since this
complication has only been described previously in
three individuals (Giagounidis et al., 1997; Rosenoff
et al., 1974; Steinkogler & Huber-Spitzy, 1988), two
E. H. Hughes et al.

of whom were receiving chemotherapy for malignant

disease and one of whom had idiopathic neutropenia.
Necrotic tissue destruction in these cases ranged from
a small lid margin notch (Rosenoff et al., 1974) to, in
the only other child reported, complete loss of lacrimal
and lid apparatus resulting in corneal exposure and
perforation (Steinkogler & Huber-Spitzy, 1988).
While examining the invasive nature of P. aeruginosa
in a neutropenic rabbit model, Ziegler and Douglas
(1979) found that the bacterium was able to invade and
destroy blood vessels without the aid of inflammatory
cells, leading to necrosis of tissue and also providing
a persistent nidus of infection. Indeed, it is interesting
that after a lengthy search for the best site to inoculate
these neutropenic animals for the induction of bacteraemia, they found that the most consistent success was
achieved with simple instillation of the bacteria into
the untraumatized conjunctival sac, from which Pseudomonas aeruginosa appeared to penetrate unimpeded.
This case provides a useful lesson that in cases of
pre-septal cellulitis the attending physician should always consider the possibility of immune compromise,
in particular where there is no obvious aetiology or in
the presence of pre-existing conjunctivitis. Early detection of this young girls underlying leukaemia and consequent changes in the antibiotic regimen may have
saved her from more severe destruction of the lid apparatus and indeed from a potentially fatal bacteraemia.

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