Annals of Indian Academy of Otorhinolaryngology Head and Neck Surgery

: 2022  |  Volume : 6  |  Issue : 1  |  Page : 22--25

Extensive facial cellulitis due to staphylococcal infection in young, immune-competent females

Pookamala Sathasivam, Vijay Pradap, Maheshwaran Shanmugasundaram 
 Department of ENT, Head and Neck Surgery, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India

Correspondence Address:
Dr. Pookamala Sathasivam
Department of ENT, Head and Neck Surgery, Velammal Medical College Hospital and Research Institute, Madurai - 625 009, Tamil Nadu


Skin and soft-tissue infections are commonly caused by Staphylococcus and Streptococcal infections. They usually cause self-limiting localized infection and responds well to antibiotic therapy. At times, they can cause dreadful infections in unfavorable conditions. Here, we discuss two cases of extensive Staphylococcal infections in healthy females. Both patients, presented with diffuse swelling of the entire half of the face. It was associated with fever, peri-orbital swelling, and swelling of upper/lower lips with multiple areas of subcutaneous pus collection. It started as a painful lesion over the cheek, which started spreading because of repeated probing of the lesion by the patients. Pus culture yielded heavy growth of Staphylococcus. In view of the massive upper airway edema, they required tracheostomy to secure airway. They were treated with intravenous antibiotics, and incision and drainage were done to relieve pus collections. They showed a dramatic response to treatment and they did not develop further complications. This article highlights the danger associated with the probing of infective lesions over the face. Young females often have a tendency to pinch acne or any other lesions over the face due to cosmetic concerns. It is essential to educate patients about the risks associated with such habits.

How to cite this article:
Sathasivam P, Pradap V, Shanmugasundaram M. Extensive facial cellulitis due to staphylococcal infection in young, immune-competent females.Ann Indian Acad Otorhinolaryngol Head Neck Surg 2022;6:22-25

How to cite this URL:
Sathasivam P, Pradap V, Shanmugasundaram M. Extensive facial cellulitis due to staphylococcal infection in young, immune-competent females. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2023 Mar 25 ];6:22-25
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Skin and soft-tissue infections are one of common human infections and they are commonly caused by Staphylococcus aureus and Streptococcal Infections.[1] They usually cause self-limiting localized infection and respond well to systemic antibiotic therapy.[2] In certain conditions like low immunity, diabetes mellitus, and infection with virulent strains, the infection can start spreading rapidly, causing progressive cellulitis, abscess formation, necrotizing fasciitis, etc. Skin and soft-tissue infections in the Head and Neck region, especially in areas around the nose and upper lip (Danger area of the face), can be dreadful, as they can cause cavernous sinus thrombosis easily due to the presence of valveless venous channels. Such complications occur very rarely in immunocompetent individuals. Here, we present two cases of diffuse cellulitis involving almost the entire face causing breathing and feeding difficulties in two young females in their twenties.

 Case Reports

Case 1

A 24-year-old female was brought to Emergency Department with symptoms of diffuse swelling of the face, reduced eye opening, fever, and decreased oral intake for the past 1 week. On eliciting a detailed history, it was noted that the patient developed a small painful pimple-like lesion over her cheek on the right side of her face around 1 week back. Then, the lesion started spreading to nearby areas after she probed the lesion. Swelling progressed to involve the entire right half of the face, leading to edema of both eyelids, swelling of lips, neck, and temporal region of the scalp. The patient did not seek any medical treatment initially. Instead, she opted for native treatment. She was referred to our tertiary care center after she developed severe eye swelling and reduced oral intake.

On examination, there was diffuse edema of the right hemi-face extending from the temporal region of the scalp to the submandibular region of the neck [Figure 1]. There was mechanical ptosis of both eyes with massive conjunctival chemosis. Multiple pus pointing lesions were seen in the cheek, forehead, eyebrow, lips, and preauricular region. Intraorally, there was fluctuant swelling in gingivo-buccal sulcus and buccal mucosa, causing trismus and pooling of oral secretions. Dental evaluation was done, and there were no dental foci of infection.{Figure 1}

The patient was admitted initially in intensive care unit in view of extensive facial and oral edema. She was started on intravenous antibiotics and fluids. She was started on intravenous ceftriaxzone and vancomycin as per our hospital antibiotic policy for presumed Staphylococcal infections. Blood investigations revealed an increase in total white blood cell (WBC) count, with increased serum pro-calcitonin. Magnetic resonance imaging scan showed extensive soft-tissue swelling in hemi-face with pus collections. After 24 h of intravenous antibiotics, she was taken up for emergency surgery to drain abscess. During the surgery, tracheostomy was done to secure the airway. Multiple incisions (below eye brow, pre-aural region, chin, submandibular region, buccal mucosa, gingiva-buccal sulcus) were made over the areas of pus collections and loculated collections were let out. She started showing dramatic improvement from the very next day of surgery.

Pus culture yielded heavy growth of Methicillin-resistant S. aureus (MRSA), showing resistance to most of the common antibiotics. Culture-directed antibiotics were started, and facial swelling resolved completely in 1 week. She developed pneumonitis in the postoperative period, which was treated in consultation with a chest physician. Incidentally, she was also found to be pregnant with a history of 8 weeks amenorrhea (diagnosed in postoperative period), and termination of pregnancy was done as she developed symptoms of threatened abortion. She received intravenous antibiotics for 2 weeks and was then discharged home after complete resolution of infection.

Case 2

20-year-old college student was brought to casualty with symptoms of fever and diffuse swelling of the entire face, eyes, and temporal region of the scalp for 10 days. On eliciting a history, it was noted that the patient initially developed a small pimple over the left side of her cheek. She kept probing the lesion, which gradually started to involve her entire face, eyelids and to the other side of her face in 1 week time. The patient did not seek any medical treatment initially. They consulted their general practitioner after she developed symptoms such as difficulty in eye opening, decreased oral intake, and breathing difficulty. Considering the extensive nature of illness, she was then referred to our tertiary care institute.

On examination, the patient was febrile, and there was diffuse edema of the entire face, predominantly on the left side. There was severe edema of both the eyelids, causing complete ptosis. Lips and cheeks were swollen and edematous, and multiple pus points were seen over their skin surface. Complete eye examination was done after retracting eyelids and there was severe conjunctival chemosis on both sides with the clear cornea and anterior/posterior chamber of the eye. Visual acuity and extraocular movements were found to be within the normal limits. On intra-oral examination, there was trismus due to fullness and swelling on the left side-buccal mucosa. There were tender fluctuant swellings in the temporal region of the scalp and parotid region. Tender, indurated swellings were seem in the submental and submandibular region of the neck. Examination of the nose, ear, and dentition was found to be within normal limits.

Blood investigations revealed raised total WBC count (23,000) with neutrophilia and markedly increased serum procalcitonin levels. Other biochemical investigations such as blood sugar levels, and renal and liver function tests, were within the normal limits. Imaging revealed diffuse inflammation involving the left half of the face [Figure 2] and [Figure 3]. She was started on empirical antibiotics (injection ceftriaxzone and vancomycin) and taken up for incision and drainage of the wound after 48 h of antibiotic injections. Temporary tracheostomy was done in view of impending airway obstruction due to trismus and submental cellulitis. During surgery, multiple nicks were made at pus points, and loculated collections were let out from both upper eyelids, temporal region, parotid region, cheek, lips, and submandibular region of the left side of the face. Intra-oral drainage of the buccal collection was done. Thorough wound debridement was done till bleeding margins.{Figure 2}{Figure 3}

Bacterial culture from wound collection, yielded heavy growth of Methicillin-sensitive S. aureus (MSSA), which was sensitive to most of the commonly used drugs against MSSA. In the postoperative period, regular wound care was given. She started showing improvement in the form of reduced eye swelling, the gradual opening of both eyes, improved mouth opening, better swallowing function and a fall in total WBC count. She received culture-directed intravenous antibiotics till complete resolution of edema and other signs of inflammation. Tracheostomy was weaned off once the neck edema resolved completely. She was discharged home after complete recovery from her illness.

 Discussion and Conclusion

S. aureus is both a commensal bacterium and a human pathogen. Approximately 30% of the human population is colonized with S. aureus.[3] It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. Skin and soft-tissue infections caused by Staphylococcus species include pyodermas, cellulitis, and pyomyositis.[4],[5]

Bacteria enter the body through any breach in skin and keratinocytes of skin, initiates an inflammatory response against the invading pathogen. Polymorphonuclear (PMN) lymphocytes are one of the first cells to reach the site of infection, and they mediate inflammatory responses to contain the infection. PMNs play a prominent role in the formation and resolution of abscesses. However, S. aureus evades this response in a multitude of ways, namely blocking chemotaxis of leukocytes; sequestering host antibodies, hiding from detection via polysaccharide capsule; biofilm formation; and resisting destruction after ingestion by phagocytes.[6]

Among the S. aureus species, Methicillin Resistant (MRSA) strains are more virulent and can present as hospital-acquired infections. However, community-acquired-MRSA (CA-MRSA) strains are also becoming increasingly common in the past decades. Among the two cases we have discussed here, Case No 1 was infected with the CA-MRSA strain. A lot of factors contribute to the virulence of the organism. Differential gene expression for proteins such as panton-valentine leukocidin, alpha-toxin, and phenol soluble modulins appears to contribute to the enhanced virulence of CA-MRSA. SasX gene was found in the S. aureus clone grown in Asia. The expression of such genes is associated with nasal colonization and pleural infection.[7]

S. aureus cellulitis most commonly involves the lower extremities, it may also involve other regions, including the upper extremities, abdominal wall, and face. It vies for primacy with streptococci as a cause of preseptal and orbital cellulitis.[8] In both of our cases, infection involved the entire half of the face and other side eyes. It started as a small papular lesion which spread rapidly to involve most of the face. Extensive involvement of facial soft tissue could be due to delay in seeking medical treatment. Both patients did not seek any medical assistance initially. They sought medical help only after the onset of severe lid edema and feeding difficulty.

In both cases, initially, it started as a small painful pimple-like lesion. When they probed the lesion, it started spreading to the cheek and neck. In 2–3 days' time, the lesion started to involve the entire hemi face with a lot of pustule formation. They mistook the pustules for chicken pox and hence sought native treatment instead. In India, it is a common practice to seek native treatment for chicken pox, mumps! Case No 1 was found to be pregnant during the postoperative period. All these factors led to rapid disease progression.

Blood investigations at the time of admission revealed an elevated total blood count of around 23,000 cells/mm3 of blood with neutrophilia and markedly elevated pro-calcitonin (32 ng/ml). In view of extensive facial soft-tissue involvement with restricted eye/mouth opening and neck swelling with features of sepsis, both of them were treated in the intensive care unit. Initially, they were started on intravenous antibiotic combination of ceftriaxone and vancomycin empirically. Later, antibiotics were changed as per the culture and sensitivity report.

Both the patients were taken up for incision and drainage of multiloculated collections under general anesthesia, and it was decided to do an elective tracheostomy to secure airway. Tracheostomy is preferred as both the patient had extensive facial and neck swelling with reduced mouth opening. Multiple nicks were made, and pus collection was let out. Both the patients showed dramatic improvement from the very next day of surgery in the form of reduction in eye swelling, gradual eye, mouth opening, and a fall in total WBC count. Antibiotics were changed once the culture report became available. In case No 1, medical termination of pregnancy was done 1 week later. She developed chest infection, and it was treated with antibiotics and chest physiotherapy. In 1 week time, both the patients showed complete resolution of facial swelling, and blood counts came back to normalcy [Figure 4].{Figure 4}

Both the patients were fortunate, as they did not develop further dreadful complications like cavernous sinus thrombosis. They were more likely to develop cavernous sinus extension, and imaging also revealed dilated ophthalmic veins in both cases. Factors like young age and the absence of other comorbidities like diabetes mellitus protected them from developing such complications.

Staphylococcal infection is one of the most common skins and soft-tissue infections. They commonly cause furuncle. Patients often have a tendency to probe/peel the lesion, especially over the face, due to cosmetic concerns. However, such an act can result in rapid local spread of the lesion and, at times, can become dreadful. Hence, such practices must be avoided, and one must educate their patients in this regard.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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