Facial cellulitis in childhood: a changing spectrum.

ABSTRACT

Background. Before conjugated Haemophilus infiuenzae type b (Hib) vaccination, a syndrome known as buccal cellulitis, usually caused by Hib and often accompanied by bacteremia, was seen. We investigated the incidence and cause of facial cellulitis at our hospital during the 10 years before and the 10 years after introduction of the vaccine.

Methods. Records of patients discharged with a diagnosis of facial cellulitis or infections of the oral cavity were reviewed. Fisher's exact test was used to compare rates of cellulitis during the two decades.

Results. Thauma was the most common antecedent to facial cellulitis in both eras. Buccal cellulitis accounted for 7/25 (28%) of cases before Hib vaccination and 0/19 cases since. Pneumococcal buccal cellulitis was not seen in either decade.

Conclusions. Buccal cellulitis due to Hib is a disappearing disease. Eighty-nine percent of recent inpatient cases of childhood facial cellulitis were related to trauma, tooth problems, or severe sinusitis. Facial cellulitis due to S pneumoniae is rare.

**********

IN THE PAST, a syndrome known as "buccal cellulitis," primarily caused by Hib infection, accounted for a fair percentage of cases of cellulitis of the face in childhood. The disease had a unique yet typical presentation. Most patients were between the ages of 3 and 24 months and had a history of mild upper respiratory tract infection, followed by rapid onset of high fever, irritability, and facial swelling. Physical examination revealed a hot, red, edematous area that often developed a violaceous hue.(1) White blood cell counts were typically high. The importance of this syndrome, as opposed to other forms of cellulitis, is that it was often accompanied by bacteremia. Blood cultures were positive in approximately 75% of cases.(2) Because of this, the development of secondary sites of infection, particularly meningitis, was a feared consequence of the disease. Lumbar puncture was a routine part of the evaluation of babies with buccal cellulitis. Although it was recognized that most cases were due to Hib infect ion, it was taught that Streptococcus pneumoniae and Staphylococcus aureus were occasional causes.(3)

The efficacy of conjugated Hib vaccine has made many diseases virtually disappear. Studies have documented the disappearance of H influenzae meningitis(4) and epiglotittis,(5) but we found no published investigation of the fate of buccal cellulitis. We attempted to document the spectrum of facial cellulitis in childhood, and to ascertain how conjugated Hib vaccine has changed the epidemiology of the disease.

METHODS

We reviewed the medical records of all patients less than 16 years of age with a discharge diagnosis of facial cellulitis or infection of the oral cavity. Patients with infections of the eye or periorbital tissues were excluded. Records for the 10-year period before the introduction of Hib vaccine (1979 to 1989) were compared with records for the 10 years after the vaccine was put into routine use (1990 to 2000). Information about the illnesses were gathered on a standardized form, and included age, sex, and race; duration, signs, and symptoms of illness; local signs; temperature at presentation; initial white blood cell count and differential count; blood, local, and cerebrospinal fluid (CSF) culture results; CSF appearance, cell count, glucose and protein levels, and Gram stain results; type and duration of antibiotic therapy, duration of hospitalization, and outcome. Reported P values are two-tailed and were derived by Fisher's exact test.

RESULTS

Of the 62 records reviewed, 30 were from 1979 to 1989, and 32 were from 1990 to 2000. Five of the 30 patients from the first period and 13 of the 32 from the second period had diagnoses other than facial cellulitis; these were excluded from the analysis.

All cases of cellulitis were classified by pathophysiologic cause into six categories: (1) trauma or non-intact skin (dog bites, wounds, severe eczema, impetigo), (2) classic buccal cellulitis, (3) odontogenic, (4) sinus-related, (5) immune-compromise-related, and (6) group B streptococcal infection of the neonate (Table 1). Buccal cellulitis accounted for more cases (7/25) in the 10 years before the introduction of Hib vaccine than in the decade afterward (0/19, P = .014).

There were 7 patients whose case history, physical examination, laboratory values, and response to therapy suggested the diagnosis of classic buccal cellulitis (Table 2). In 3, the diagnosis of H influenzae buccal cellulitis was proven by recovery of the bacterium by blood culture. The other 4 patients were categorized as probable cases based on the classic clinical history and presentation of the illness. All of these patients were between the ages of 3 and 16 months, and all were male. Most had high fever and elevated white blood cell counts with a high percentage of neutrophils. Four of the 7 had a documented antecedent infection of the upper respiratory tract.

DISCUSSION

Facial cellulitis is an uncommon pediatric disease. Before the introduction of the Hib vaccine, a distinct clinical syndrome associated with Hib infection (often accompanied by bacteremia) was seen in young children. The propensity of H influenzae to cause cellulitis localized to the cheek was never completely explained. Some experts argued that the disease began with an episode of acute otitis media, and the bacteria tracked into the buccal space through lymphatic vessels. (6) Some believed that intraoral trauma, often not noticed clinically, caused the bacteria to get into the cheek from inside the mouth. The prevailing opinion was that buccal cellulitis was initiated by bacteremia. (7) With appropriate antimicrobial therapy, the majority of patients showed rapid clinical improvement, becoming afebrile within 24 hours. The prognosis of the syndrome was uniformly good, provided appropriate therapy was given and meningitis had not developed.

Vaccination against Hib has virtually eliminated many syndromes formerly seen with some regularity. This report confirms our clinical suspicion that buccal cellulitis is also a disappearing disease. Whereas during the 10 years before the introduction of the Hib vaccine, buccal cellulitis accounted for almost a third of cases, not a single case has been encountered during the past 10 years at our busy pediatric hospital (currently averaging 5,000 admissions per year). Although in the absence of positive cultures, Hib cannot be conclusively shown to be the cause of the clinical syndrome in 4 of these patients, the clinical history, presentation, and laboratory findings support the diagnosis. Furthermore, the complete absence of this type of case during the 10 years after Hib vaccination was instituted, despite an increasingly busy hospital service, buttresses this supposition.

Facial cellulitis in pediatric practice is now largely due to (1) trauma/loss of skin integrity with secondary infection, (2) dental problems, or (3) severe sinusitis. These three underlying causes accounted for 89% of the cases of facial cellulitis seen at our hospital during the past decade. Although the numbers did not reach statistical significance, there was a trend toward an increasing number of facial infections due to severe sinus disease. Facial cellulitis accompanying group B streptococcal sepsis in newborns also was not seen during the past 10 years. However, this condition was rare even in the previous decade.

In summary, although the diagnosis of facial cellulitis is still made in pediatric patients, buccal cellulitis (the second most common cause in the pre-Hib vaccine era) is now extremely rare. The disease is rarely caused by S pneumoniae; a recent longitudinal study spanning 5 years at 8 of the largest pediatric centers in the country found only 7 cases. (8) We were unable to document a single case of facial cellulitis proven to be due to S pneumoniae infection at this institution in 20 years. Cellulitis of the face due to sinus infections may be slightly more common now than it was in the past.

TABLE 1

Causes of Facial Cellulitis in Children in the Pre-Hib and Post-Hib
Vaccine Eras

                         No. of      No. of
                       Patients--  Patients--
Category               1979-1989   1990-2000   P Value

Trauma                  12 (48%)    9 (47%)     >.99
Buccal cellulitis        7 (28%)    0            .014
Odontogenic              2 (8%)     5 (26%)      .21
Sinuses                  0          3 (16%)      .07
Immune compromise        2 (8%)     2 (11%)     >.99
Group B streptococcus    2 (8%)     0            .5

Total                   25         19
TABLE 2

Clinical Characteristics of Patients With Proven or Suspected Buccal
Cellulitis

               Upper         Duration
  Age       Respiratory    of Illness *  Temperature  White Blood
(months)  Tract Infection    (hours)         (C)      Cell Count

   8            NA              24          37.8         21.5
   3.5          Y               24          37.4         36
   9            NA              24          38.8         35.4
   6            Y               24          39.7         19.2
   7            Y               24          39.3         18.5
   4.5          Y               12          39.9         27.4
   16           NA              24          39.0         16.8

           Segmented                      Cerebrospinal
  Age     Neutrophils/   Blood    Local       Fluid
(months)    Bandforms   Culture  Culture     Culture

   8          57/0        NG       ND          ND
   3.5        72/1        NG       NG          NG
   9          61/3        NG       ND          ND
   6          48/29       Hib      NG          NG
   7          42/30       Hib      NG          NG
   4.5        52/26       Hib      Hib         ND
   16         65/7        NG       NG          NG

* From onset of swelling to hospital presentation.

Hib = Haemophilus influenzae type b, NG = no growth, ND = not done, NA =
not available.

References

(1.) Feingold M, Gellis SS: Cellulitis due to Haemophilus influenzae type b. N Engl J Med 1965; 272:788-789

(2.) Rapkin R, Gautista C: Hemophilus influenzae cellulitis. Am J Dis Child 1972; 124:540-542

(3.) Thirumoorthi MC, Asmar BI, Dajani AS: Violaceous discoloration in pneumococcal cellulitis. Pediatrics 1978; 62:492-493

(4.) Dawson KG, Emerson JC, Burns JL: Fifteen years of experience with bacterial meningitis. Pediatr Infect Dis J 1999; 18:816-822

(5.) Hickerson SL, Kirby RS, Wheeler JG, et al: Epiglottitis: a 9-year review. South Med J 1996; 89:487-490

(6.) Nelson JC, Ginsburg CM: An hypothesis on the pathogenesis of Hemophilus influenzae buccal cellulitis. J Pediatr 1976; 88:709

(7.) Landwirth J: Bilateral cellulitis of cheeks in an infant due to Hemophilus influenzae. Clin Pediatr 1977; 16:182-184

(8.) Givner LB, Mason EO Jr, Barson WJ, et al: Pneumococcal facial cellulitis in children. Pediatrics 2000; 106:e61

RELATED ARTICLE: KEY POINTS

* The disease known as buccal cellulitis, which was due to Haemophilus influenzae type b infection and was often accompanied by bacteremia, is a disappearing disease in the post-Hib vaccine era.

* Trauma/loss of skin integrity is the most common antecedent to facial cellulitis in childhood.

* Facial cellulitis due to Streptococcus pneumoniae is rare.

From the Department of Pediatrics, Division of Infectious Diseases, Duke University Medical Center, Durham, NC.

Reprint requests to Randall G. Fisher, MD, Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Department of Pediatrics, 601 Children's Lane, Norfolk, VA 23507.