Case Report|Articles in Press

Preseptal cellulitis with Streptococcus pyogenes complicated by streptococcal toxic shock syndrome: A case report and review of literature

Published:April 21, 2023DOI:


      Preseptal cellulitis, an infection of the eyelid and skin around the eye, can be distinguished from orbital cellulitis. It is common in children and is rarely complicated. Streptococcus pyogenes is one of the major pathogens causing preseptal cellulitis. Here, we report a case of a 46-year-old man with carcinoma of unknown primary presenting preseptal cellulitis of S. pyogenes complicated by streptococcal toxic shock syndrome and multiple metastatic abscesses involving right eyelid, subcutaneous tissue in the scalp, mediastinum, bilateral pleural spaces, pericardial space, and the left knee. Although he required a prolonged hospitalization, antibiotic therapy and multiple courses of debridement led to full recovery. A literature review revealed that there were only four cases of preseptal cellulitis with S. pyogenes in adults and two cases were complicated by streptococcal toxic shock syndrome. The cases had either trauma or immunocompromising factors similar to our patient. All patients survived with antibiotic therapy and debridement, and the functional outcome was favorable. In summary, preseptal cellulitis caused by S. pyogenes can be severe in adult cases where immunocompromising factors and type of strain may play a role in the severity of the disease. Awareness of the risk of severe complications, treatment with appropriate antibiotic therapy, and timely debridement are crucial for favorable prognoses.



      STSS (streptococcal toxic shock syndrome), Spe (streptococcal pyrogenic exotoxin)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Infection and Chemotherapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Baiu I.
        • Melendez E.
        Periorbital and orbital cellulitis.
        JAMA. 2020; 323: 196
        • Liu I.T.
        • Kao S.C.
        • Wang A.G.
        • Tsai C.C.
        • Liang C.K.
        • Hsu W.M.
        Preseptal and orbital cellulitis: a 10-year review of hospitalized patients.
        J Chin Med Assoc. 2006; 69: 415-422
        • Gordon A.A.
        • Phelps P.O.
        Management of preseptal and orbital cellulitis for the primary care physician.
        Disease-a-Month. 2020; 66101044
        • Meyer M.A.
        Streptococcal toxic shock syndrome complicating preseptal cellulitis.
        Am J Ophthalmol. 1997; 123: 841-843
        • Ingraham H.J.
        • Ryan M.E.
        • Burns J.T.
        • Shuhart D.
        • Tenedios G.
        • Malone W.
        • et al.
        Streptococcal preseptal cellulitis complicated by the toxic streptococcus syndrome.
        Ophthalmology. 1995; 102: 1223-1226
        • Barry J.S.
        • Burge J.A.
        • Byles D.B.
        • Morgan M.S.
        Severe invasive β haemolytic group A streptococcal cellulitis and eyelid necrosis treated with linezolid.
        Br J Ophthalmol. 2006; 90: 1204
        • Rao V.A.
        • Hans R.
        • Mehra A.K.
        Pre-septal cellulitis-Varied clinical presentations.
        Indian J Ophthalmol. 1996; 44: 225-227
        • Sagiv O.
        • Thakar S.D.
        • Kandl T.J.
        • Kontoyiannis D.P.
        • Debnam J.M.
        • Esmaeli B.
        Clinical course of preseptal and orbital cellulitis in 50 immunocompromised patients with cancer.
        Ophthalmology. 2018; 125: 318-320
        • Luca-Harari B.
        • Darenberg J.
        • Neal S.
        • Siljander T.
        • Strakova L.
        • Tanna A.
        • et al.
        Clinical and microbiological characteristics of severe Streptococcus pyogenes disease in Europe.
        J Clin Microbiol. 2009; 47: 1155-1165
        • Nelson D.C.
        • Garbe J.
        • Collin M.
        Cysteine proteinase SpeB from Streptococcus pyogenes – a potent modifier of immunologically important host and bacterial proteins.
        Biol Chem. 2011; 392: 1077-1088
        • Chiang-Ni C.
        • Wu A.B.
        • Liu C.C.
        • Chen K.T.
        • Lin Y.S.
        • Chuang W.J.
        • et al.
        Emergence of uncommon emm types of Streptococcus pyogenes among adult patients in southern Taiwan.
        J Microbiol Immunol Infect. 2011; 44: 424-429