Acute Bilateral Eyelid Edema in a 3-Year-Old Girl With Pyuria

Abstract

A 3-year-old Asian girl presented to the emergency department with high fever (>40°C) of 2 days' duration, bilateral upper and lower eyelid edema, and dysuria. Results of urinalysis revealed pyuria, and she was prescribed oral cephalexin, 250 mg every 12 hours, for a presumed urinary tract infection. The patient returned 2 days later with persistent fever, worsening eyelid edema, and a new macular rash over her buttocks and shins. At this time, the ophthalmology service was consulted owing to concern for Stevens-Johnson syndrome precipitated by the treatment with cephalexin.On examination, her visual acuity was central, steady, and maintained in each eye. Motility and pupil reactions were normal. There was moderate edema of the upper and lower eyelids bilaterally with erythema and several areas of shallow ulceration that were weeping a yellowish serous discharge (Figure , A). This type of edema was associated with moderate hyperemia of the palpebral conjunctiva (Figure , B). Results of the ocular surface examination revealed minimal bulbar conjunctival injection, the cornea was clear, and there was no discharge. Cephalexin was discontinued, the patient was admitted, and a diagnostic workup was initiated, including swabs from the eyelid lesions and conjunctiva for bacterial cultures and viral polymerase chain reaction testing. Results of blood laboratory testing revealed an elevated erythrocyte sedimentation rate and an elevated level of C-reactive protein, as well as elevated liver enzymes. Moderate edema of upper and lower eyelidsA Moderate hyperemia of palpebral conjunctiva B Figure. On initial evaluation, the patient displayed bilateral eyelid edema and erythema with multiple areas of shallow ulceration (A) and moderate palpebral conjunctival hyperemia (B). WHAT WOULD YOU DO NEXT? A. Start corticosteroid eyedrops and check daily for pseudomembrane formation B. Perform echocardiography and administer intravenous immunoglobulin C. Perform Tzanck smear on swab from ulcerated lesion D. Institute contact precautions and prescribe mupirocin ointment to eyelid skin Clinical Review & Education