Acute Myelogenous Leukemia Mimicking Fulminant Periorbital Cellulitis
A 17-year-old boy presented with fever, progressive swelling and erythema of the right upper and lower lids and periorbital soft tissues of 5 days’ duration (A). He had received intramuscular gentamicin and oral ciprofloxacin over the last 5 days. He had no history of trauma, systemic disease or insect bites. No abnormal findings such as lymphadenopathy or hepatosplenomegaly were noted on systemic physical examination. He was ill and had high grade fever. Visual acuity was 8/10 in both eyes and relative afferent pupillary defect was negative. Ocular motility was normal but painful in the affected eye. Slit lamp examination and funduscopy were unremarkable and intraocular pressure was within normal limits. The patient had no evidence of dental infections or dacryocystitis. A complete blood count (CBC), blood culture, and other laboratory tests were requested.\nThe patient was admitted with a clinical impression of preseptal cellulitis and impending orbital involvement; intravenous ceftriaxone 1 gm every 12 hours was initiated empirically. The swelling and erythema progressed throughout the right facial and left periorbital area, and some blisters appeared on the right upper eyelid the day after admission (B). Orbital and paranasal sinus computed tomography (CT) images showed right periorbital soft tissue swelling without sinus involvement (). Laboratory tests revealed leukocytosis (120,000/ml) with a predominance of immature blast cells (>90%), anemia (hemoglobin level 10.9 gm/dl) and thrombocytopenia (54,000/ml).\nThe patient was referred to a hematologist with a presumptive diagnosis of acute leukemia and underwent bone marrow aspiration (BMA) and flow cytometry which confirmed type M4-M5 AML (). Chemotherapy including cytarabine 100 mg/m2 and idarubicin 12 mg/m2 together with broad spectrum antibiotics including vancomycin 1 gm every 12 hours, ceftazidime 1 gm every 8 hours and imipenem 500 mg every 6 hours were initiated. Signs and symptoms regressed after two courses of chemotherapy over 2 months and he was relapse free for 2 years (C).