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JAMA Pediatrics Clinical Challenge

Adolescent With Right Orbital Swelling and Proptosis

Image of figure 1


Tiffany S. Chang, BA
Savitha M. Sunkara, MD
Anthony S. Cooley, MD

An adolescent boy presented to our hospital with a 5-day history of right eyelid swelling and redness accompanied by blurred vision and pain with ocular movement. This was his third hospitalization for these symptoms; the previous admissions were 2 and 4 months earlier, with no symptoms in the intervals. During the prior admissions, treatment included antibiotics for orbital cellulitis and corticosteroids for suspected antibiotic allergies.

Physical examination was notable for right upper and lower eyelid edema and erythema, conjunctival hyperemia, chemosis, and proptosis (Figure, A). The left eye appeared normal at admission. However, within 24 hours after admission, our patient developed left chemosis with eyelid edema and erythema. His vision and pupillary responses were normal. Fundus examination revealed mild blurring of the disc margins only on the right side. Slitlamp examination identified numerous cells in the right anterior chamber. Extraocular movements were limited in all directions in both eyes, with a larger deficit in the right eye.

Computed tomography (Figure, B) and magnetic resonance imaging (MRI) (Figure, C) of the orbit were performed. The results of these examinations, in conjunction with the patient’s history, prompted biopsy.

See the full article for an explanation and discussion.

Author Affiliations: Chang is affiliated with the School of Medicine, Emory University, Atlanta, Georgia, Sunkara is affiliated with the Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, and Cooley (anthony.cooley@emory.edu) is affiliated with the Division of General Pediatric Hospitalists, Department of Pediatrics, School of Medicine, Emory University, and Children’s Healthcare of Atlanta, Atlanta, Georgia.