A six-year-old boy presented with a 24-hour history of fever and eye pain in March, and cough, mucus, and fever since the previous 3-4 days.
The examination showed pain with ocular mobility, minimal redness in the right lower eyelid, without proptosis, normal pupils and normal visual acuity.
The patient was referred to the hospital for evaluation, where these complementary tests were performed: blood count with leukocytes 16 680/μl (N: 86.5%; L: 9.8%; M: 2.4%); PCR, 135 mg/l.
Amoxicillin/clavulanic acid was administered orally at a dose of 80 mg/kg/day, and possible complications were reported.
After 24 hours, the patient consulted again due to persistent pain. Examination showed increased redness and edema of the eyelid without proptosis, normal pupils and normal visual acuity.
CT of both orbites revealed a subperitic sinus abscess at the maxillary sinus along the medial wall of the orbita, with lateral displacement of the medial rectus muscle, right proptosis, and right celdillas.
With the diagnosis of orbital colitis with probable origin in a sinus, she was admitted to hospital and was treated with intravenous cefoxime and clindamycin for seven days. She was discharged with amoxicillin/clavulanic acid 14 days.
The evolution was favorable.
