A one-year-old boy presented to the emergency department with a sudden onset of fulminant edema of the right eyelid, making it impossible to open his right eye (Figure 1 ). The ophthalmologic examination showed painful eyelid edema with conjunctival chemosis. Due to the extensive eyelid swelling, it wasn’t possible to examine pupillary light reflexes or ocular motility nor to perform a fundus examination. The boy had a temperature up to 39.1°C. Physical examination showed an alert patient, without neurological or meningeal signs, but with cutaneous varicella lesions spread over his entire body.\nLaboratory work up showed normal leukocytes (9.23 x 103/µl), thrombocytopenia (platelets 67 x 103/µl) and elevated CRP (52 mg/l). The boy hadn’t received his vaccination for varicella yet, which usually takes place between the age of 12 to 15 months. Clinical examination couldn’t exclude orbital cellulitis and revealed multiple enlarged lymph nodes in the neck region. There was a clinical suspicion of a secondary bacterial infection of the cutaneous varicella lesions around the eyelid. CT of the orbit revealed pronounced superficial soft tissue inflammation of the right periorbit without evidence of an intraorbital inflammation or abscess formation, cavernous sinus thrombosis or intracranial extension of the inflammation (Figure 2 ).\nThe boy was hospitalized for a trial of intravenously antiviral (acyclovir) and antibiotic therapy (amikacin, flucloxacillin, and ceftriaxone). The antibiotic therapy was changed to clindamycin after 2 days due to poor clinical response with also increasing swelling of his left eyelid (Figure 1 ). In immunocompetent children, VZV usually causes a benign infection without the need for systemic antiviral treatment, in this case the pediatrician decided to treat the varicella infection with intravenously acyclovir for 5 days (30 mg/kg/day in 3 divided doses). The laboratory markers of inflammation raised with a maximal leucocytosis of 23.8 x 103/µl and a CRP level of 190 mg/l. There weren’t any clinical signs of sepsis. The peripheral blood count and culture of vesicular fluid obtained at the emergency department were negative. On the second day of admission, the right upper eyelid ruptured spontaneously (Figure 1 ). We removed the overlying crusts and debris and took a swab of the underlying ulcer. Culture grew the anaerobic organism Veillonella parvula, without identifying any other bacterial or fungal organisms. Clindamycin was continued to cover anaerobe bacteria. The antibiogram showed resistance to penicillin, amoxicillin clavulanic acid and even metronidazole, but sensitivity to clindamycin and meropenem. The source of infection was most likely a superinfection of the varicella skin lesion. Clindamycin was given intravenously for 3 weeks with a good clinical response showing a slow but progressive decline of the eyelid edema. When the boy was discharged from the hospital, clindamycin was continued orally for another 4 weeks, resulting in a total antibiotic treatment duration of 7 weeks. The eyelid swelling with a hardened eyelid persisted for 4 months. Because of this, the boy was unable to fully open his eye in the first 4 months, obscuring the child’s visual axis and putting him at great risk for developing occlusion amblyopia (Figure 3 ). The patient gained a full recovery with a complete resolution of the eyelid edema and a clear visual axis without need for surgical intervention. He is still in follow-up with a pediatric ophthalmologist for regular amblyopia screening and early treatment if necessary.
A 76-year-old male diagnosed with Veillonella bacteremia presented with a sudden onset of back pain, fever, and chills of four days duration. Although the fever and chills had since subsided, the back pain continued to persist and was exacerbated with positional change. CT scans revealed a psoas abscess with extradural extension, along with indications of lumbar osteomyelitis. MRI scans were unable to be obtained owing to the patient’s pacemaker. Due to medication allergies and growing sensitivity to the infection, the patient was transferred to MICU for a short period to be desensitized to ampicillin-sulbactam. Interventional Radiology then placed a retroperitoneal drain for the psoas abscess as well as a PICC line for IV antibiotic administration at home.\nDuring the following week, the Neurosurgery service performed laminectomy at levels L4-S1. Bilateral medial facetectomies and foraminotomies were also performed at L4-L5 and L5-S1 to fully decompress the exiting nerve root and thecal sac. Significant facet arthropathy was noted. The extradural abscess, which was revealed to be a large synovial cyst with no pus, was resected. Cultures were taken and sent for laboratory analysis, revealing the presence of Veillonella species. Post-operatively, CT scans indicated a resolving abscess. The patient was discharged and instructed to complete his course of ampicillin-sulbactam at home and switch to metronidazole and levofloxacin for a total six-week course of antibiotics.\nThe patient re-presented to the hospital 18 days after the neurosurgical operation complaining of worsening back pain radiating into his posterior buttocks that began 10 days after the operation. CT scans revealed considerable interval decrease in the psoas abscess but extensive osseous destruction in the L5-S1 region, anterior to the laminectomy sites, thereby advancing concerns of osteomyelitis. CT scans revealed trace retrolisthesis of L2 on L3 and L3 on L4, as well as grade 1 anterolisthesis of L4 on L5. There was multilevel disc height loss, most severe at L3-L4 and L5-S1, and persistent narrowing of the thecal sac. Fluid was observed posterior to the surgical site along with phlegmonous changes extending from L4-S1. A small abscess was also seen in the S1 prevertebral soft tissues. Interval erosions of the L5 and S1 endplates were noted, compatible with discitis. All of these findings were consistent with progressive osteomyelitis. Furthermore, bone and tissue cultures revealed continued Veillonella infection, perhaps due to a combination of both insufficient debridement as well as inadequate duration of antibiotic treatment. The patient was instructed to begin IV vancomycin in addition to metronidazole and levofloxacin for an additional 6 weeks.\nThe patient presented to the office 25 days later with unbearable, radiating lower back pain forcing him to use a wheelchair to move about. CT scans indicated progressive destructive changes of the L5-S1 vertebral body endplates. Two presacral abscesses measuring 4 mm and 7 mm were identified anterior to S1; additional microabscesses were found in the prevertebral phlegmon at the L5 level. A larger abscess measuring 15 mm was identified dorsal to the thecal sac at the previous L5 laminectomy site, leading to a narrowing of the dural sac. Progressive destruction of the vertebral bodies was noted with fragmentation of the inferior endplate of L5 and superior endplate of S1. Reflexes were absent bilaterally in the lower limbs and there was decreased sensation to light touch. Tissue cultures taken from the affected vertebrae were all negative at this time, and given the patient’s debilitated status, reconstructive spine surgery was indicated.\nPreoperative X-ray revealed spondylolisthesis of L5 on S1, and a CT myelogram showed severe multilevel spinal stenosis from L2 to S1. Therefore, the patient underwent a L2-S1 lumbar laminectomy with posterior segmental instrumentation and posterolateral arthrodesis from the L2 to the ilium using pedicle screws and iliac bolts bilaterally. Decompression of spinal nerves was achieved by posterior lumbar laminectomy, bilateral medial facetectomies, and bilateral foraminotomies at all spinal levels between L2 and S1. Given the patient’s history of infection, an allograft was used to form a final instrumented fusion mass. (Figs. , , , and ).\nThe patient recovered well after surgery. Final blood and tissue cultures were all negative. CT scans indicated resolution of the remaining abscesses. He was discharged and instructed to complete the previously prescribed course of antibiotics and follow-up with rehabilitation facilities. After 12 months of rehabilitation therapy, the patient regained a majority of mobility and ambulated with cane. However, at the 12 month follow up visit, he complained of groin pain. Additional physical therapy including aqua therapy was ordered and followed. At the 18 month follow up visit, the patient is noted to be doing quite well with occasional back discomfort and continues to ambulate with a cane.