Case Description:
A 36-year-old male with history of asthma, hypertension, uncontrolled diabetes, and obesity presented with sudden onset of redness and swelling in the right eye that started 6 days prior to hospitalization, and was gradually getting worse. He initially went to an urgent care where he was prescribed cephalexin 500 mg twice a day. After 2 days, he did not notice significant relief, and developed a new blurry vision associated with photophobia in the right eye. Later, he spiked a fever of 103oF at which point he decided to come to the hospital, and got admitted. He denied reports of trauma, local injury, swimming pool exposure, and use of contact lens. He denied any recent sick contacts and lives with his spouse and three young kids, none of whom were sick in recent times. He reported a monogamous relationship with his wife and denied any history of sexually transmitted diseases. He denied intravenous drug use, smoking, or alcohol use. He had two pet dogs, none of whom were sick with similar illness. His vital signs were stable at presentation except for fever as mentioned above. On examination, he had severe redness of palpebral conjunctiva with diffuse sub-conjunctival hemorrhage. Upper and lower right eyelid showed redness, ecchymoses, swelling, crusting and discharge from the corner of his right eyelid (Figure 1).
His left eye was normal. Pupils were equally reactive to light on both sides. Intraocular pressure measured by tono-pen was within normal limits. Visual field testing showed mild generalized constriction of visual field of the right eye. Bilateral corneas, anterior chamber, iris, and lenses were grossly normal without any abnormality. Fundoscopic examination via indirect ophthalmoscopy after pupillary dilatation showed normal vitreous, and absence of retinal or optic disc changes. All cranial nerves were intact and extraocular muscles showed full range of motion with tenderness on full extension. Motor, sensory exam, and reflexes were equal and bilaterally symmetrical.
Upon admission, he was started on broad spectrum antibiotics. White blood cell count, hemoglobin, platelets, serum electrolytes, serum creatinine, and liver function tests were all within normal limits except for an elevated blood sugar of 268 mg/dL (normal range [NR]: 70-110 mg/dL). Procalcitonin was normal at 0.04 ng/mL (NR: less than 0.1 ng/mL), erythrocyte sedimentation rate was elevated at 54 mm/hour (NR: 1-13 mm/hour), C-reactive protein was 0.94 mg/dL (NR: less than 1 mg/dL). HIV 1&2 antigen and antibody test were negative. Magnetic resonance imaging (MRI) of face showed preseptal soft tissue thickening consistent with cellulitis. Ocular globe, post-septal space, ocular lenses, extra-ocular muscles, optic nerve sheath, lacrimal glands, and retro-bulbar fat appeared normal with no involvement from infection (Figure 2).
Blood cultures returned negative after 5 days of incubation. Serum sample was sent for microbial cell-free DNA test also known as meta-genomic testing. It showed 459 DNA molecules per microliter (MPM) of human adenovirus D in the serum sample with normal range of less than 10 MPM. The patient was started on topical steroids, and he responded well with significant improvement in signs and symptoms within first 3 days. Antibiotics were discontinued, and the patient was discharged home with no sequelae at the follow-up visit.