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 79-year-old man presented with a 1-month history of constant lower back pain (LBP) radiating to the right thigh. The pain had been increasing over time. Movements aggravated the symptoms. The patient reported 10 out of 10 points in the visual analog scale. He was afebrile but reported intermittent chills at night. There was no history of recent gastrointestinal procedures, dental diseases/procedures, oncological diseases, immunodeficiency, diabetes, or intravenous drug use.\nOn examination, the lumbar paravertebral muscles were tender, hip flexion on the right side revealed slightly paresis (M4/5), and minimal movement of the spine or the limbs was accompanied by severe pain.\nOn admission, the inflammation markers were elevated (C-reactive protein [CRP] 54,4 mg/l, white blood cells [WBC] count = 13,6 G/l, platelet count = 344 G/l). X-ray and a ct-scan of the lumbar spine revealed destruction of the intervertebral space L3/4 and the corresponding endplates. Because of the bony destruction, the L4-body presented an anterior wedging. The standing X-ray revealed a segmental kyphosis as a result of the wedge deformity of L4-body and the collapsed disc space L3/4 []. Blood cultures taken on admission were negative. During the next 12 h, the pain got worse, and the patient developed urinary retention, which required a bladder catheterization. MRI-scan of the lumbar spine 12 h after admission revealed an advanced spondylodiscitis L3/4 with a liquefied disc, blurred endplates, and a collection of two abscesses in the right psoas muscle. Furthermore, a diffuse signal enhancement in both psoas muscles and the autochthone muscles from L3 to S1 [] was shown. A ct-guided fine needle biopsy was performed, and the empiric intravenous antibiotic therapy with amoxicillin/clavulanate 2.2 g 4 times daily intravenously (iv.) was initiated. As the results of the biopsy did not show any growth of bacteria amoxicillin/clavulanate was stopped. After an antibiotic-free interval of 5 days (9 days after the CT-guided biopsy), an open transpedicular biopsy was performed. On the same day, iv. amoxicillin/clavulanate was resumed. The bacteriological examinations on aerobic/anaerobic cultures showed no results. The eubacterial PCR (16S rDNA-sequencing) revealed V. parvula as the causing pathogen. The antibiotic therapy was switched to ceftriaxone 2 g iv. and metronidazole 500 mg i.v. A CT of the abdomen was performed on day 21, which showed increasing abscess collection in the right psoas major of 4.1 × 4.6 cm [] but no signs of intraabdominal malignancy. A drain was inserted into the right psoas muscle, and the abscess formation was subsequently drained for 4 days.\nAbnormal high calcium levels revealed an incidental parathyroid adenoma, which had to be removed surgically. Because of the additional surgery, the patient was discharged on day 27. On day 39, the patient presented himself in good health and pain-free to our outpatient clinic. Inflammation markers had normalized (CRP 2 mg/l, normal WBC count). A small residual abscess collection in the right psoas muscle was discovered on CT scan. The CT-scans and the standing X-rays of the lumbar spine showed no instability of the spine without any progression of the kyphotic deformity L3/L4. The antibiotics were switched to amoxicillin/clavulanate 1 g po 3 times daily for another 2 weeks, completing 6 weeks of the antibiotic treatment altogether. The patient presented himself to the last follow-up at day 95 in perfect shape, without any symptoms, and further changes in the lumbar spine X-rays [].\nThere was no external immobilization of the spine during the whole duration of the treatment.