Sir,

Intralesional corticosteroid injection is a treatment for capillary haemangioma of the orbit and eyelid which rarely gives rise to serious complications.1 We report a case of orbital cellulitis following treatment for periocular capillary haemangioma.

Case report

A 2-month-old infant presented with a left lower lid swelling and non-axial proptosis. Magnetic resonance imaging (MRI) revealed a haemodynamically high-flow lesion suggestive of a capillary haemangioma (Figure 1) in her inferior orbit. Oral prednisolone (15 mg twice daily) was initiated with no response after 6 weeks. A preseptal injection of triamcinolone 40 mg/ml and betamethasone 4 mg/ml was then given under aseptic conditions. A post-septal injection under ultrasound guidance was performed 6 months later.

Figure 1
figure 1

Photo on the left showing a large lower lid swelling causing non-axial proptosis and a coronal MRI scan on the right showing flow voids in the left orbit suggestive of a capillary haemangioma.

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Four weeks after the second injection, there was a sudden increase in size of the lesion. MRI revealed an increase in soft tissue density with loculated areas of contrast enhancement (Figure 2), suggestive of an abscess in the inferior orbit. She was afebrile and blood cultures were negative. Intravenous amoxicillin, clavulanic acid, and gentamicin were started and she underwent drainage of the abscess. Laboratory studies confirmed a capillary haemangioma and the presence of Staphylococcus aureus, Streptococcus viridans, and Acinetobacter. She presented again with a recurrence of infection 3 weeks later, which required another surgical drainage and a further 2 weeks of antibiotics. She has remained well at her last follow-up aged 2 years.

Figure 2
figure 2

Sagittal and coronal MRI showing an inferior fluid collection in the left orbit suggestive of an abscess.

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Comment

Intralesional corticosteroid injection is the most common treatment for capillary haemangiomas and 76% of clinicians use a combination of triamcinolone and betamethasone.1, 2 Various local (eg, skin, fat atrophy, and necrosis3) and systemic (eg, Cushingoid features, growth retardation4) complications have been described but orbital cellulitis had only been previously reported in low-flow vascular malformations.5

In our patient, we postulate that the needle tract created during the injection could have served as a site for entry of pathogens. The concurrent use of systemic prednisolone may have induced an immunocompromised state, increased her susceptibility to infection, and caused delayed wound healing leading to the late onset of infection.

Although intralesional corticosteroid remains the treatment of choice and is generally safe, clinicians should still be wary of the potential morbidity associated with this procedure.