A 7-year-old boy is brought to the emergency department by his parents due to left eye swelling and redness. The patient has had left eye pain for 2 days and the pain worsened today. He has no symptoms in his right eye. He has allergic rhinitis, for which he takes intranasal steroids. The patient developed sinusitis approximately 3 weeks ago and was treated with amoxicillin-clavulanate. He has no other medical conditions and has had no surgeries. The patient's mother was diagnosed with left leg deep vein thrombosis after a recent transatlantic flight. Temperature is 39.2 C (102.5 F), blood pressure is 102/70 mm Hg, pulse is 94/min, and respirations are 18/min. The left eyelid is erythematous, tender, and swollen. The conjunctiva is hyperemic. Movement of the left eye causes pain. Visual acuity and pupillary reaction are normal bilaterally. Purulent mucus is draining from the nose, and nasal turbinates are swollen and erythematous. Examination of the right eye is unremarkable, and facial sensation is intact. Item 1 of 3 Which of the following findings is most concerning in this patient?

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Explanation: This patient has an erythematous, swollen eyelid, conjunctivitis, and fever. These findings are consistent with both preseptal and orbital cellulitis. Orbital cellulitis is more concerning and can be differentiated from the less serious, but more common, preseptal cellulitis by identifying signs or symptoms suggestive of intra-orbital inflammation. Only orbital cellulitis involves the post-septal (ie, orbital) structures such as the extraocular muscles (ophthalmoplegia, painful eye movements) and orbital fat (proptosis). The most common predisposing factor for orbital cellulitis is sinusitis, and the causative organisms are identical to those that cause sinusitis in children. These include sinogenic organisms such as viridans group streptococci and Streptococcus pneumoniae as well as Staphylococcus aureus, although more than one organism is often identified. Preseptal cellulitis may be secondary to sinusitis but more commonly is due to breaks in the skin. As a result, S aureus and S pyogenes are common causes of preseptal cellulitis. (Choices A and B) Chemosis (hyperemic conjunctiva) and eyelid swelling are nonspecific findings that can be seen in both preseptal and orbital cellulitis as well as less severe conditions such as conjunctivitis. (Choice B) A first-degree relative with a deep venous thrombosis raises concern for an inherited hypercoagulation disorder. However, hypercoagulability is not involved in the pathogenesis of orbital cellulitis. (Choice C) Fever is a nonspecific finding that is seen in many infectious and noninfectious conditions. Although fever requires evaluation, this patient's temperature is not a concerning finding in itself. Educational objective: Both preseptal and orbital cellulitis can present with eyelid redness and swelling, fever, and conjunctivitis. However, orbital cellulitis can be distinguished from preseptal cellulitis by the presence of pain with eye movement, proptosis, or ophthalmoplegia. References: Differential diagnosis of the swollen red eyelid. (http://www.ncbi.nlm.nih.gov/pubmed/18217520)

A 7-Year-Old Boy Is Brought to the Emergency Department by His