Management of refractory periorbital abscesses caused by Streptococcus constellatus: case report

BACKGROUND: Streptococcus constellatus is recognized for its propensity for aggressive abscess formation; however, its refractory nature in periorbital infections remains underemphasized in the literature. This study aims to present two cases of treatment-resistant periorbital abscesses and delineate a successful multidisciplinary management protocol, complemented by a review of previously reported cases to provide a comprehensive clinical perspective. CASE PRESENTATION: The first case involves a 25-year-old male who presented with a three-day history of a maxillary dental abscess followed by 24 h of left periorbital swelling and restricted ocular motility. Orbital magnetic resonance imaging (MRI) confirmed cellulitis with a subperiosteal abscess. Despite initial surgical intervention, persistent purulence necessitated subsequent daily bedside drainage. Cultures identified S. constellatus. Functional and aesthetic outcomes were optimized through the targeted use of 5-fluorouracil (5-FU) to mitigate post-inflammatory fibrosis. The second case describes an 18-year-old autistic male with poor oral hygiene presenting with a two-day history of left periorbital edema. Computed tomography (CT) revealed a 5 cm subcutaneous collection. Alongside broad-spectrum intravenous antibiotic therapy, the patient underwent five days of daily drainage and ceftazidime irrigation. Cultures similarly identified S. constellatus, and he achieved full functional and cosmetic recovery. DISCUSSION AND CONCLUSIONS: S. constellatus can precipitate aggressive, treatment-resistant periorbital abscesses. Early multidisciplinary intervention, including targeted systemic antibiotics, repeated surgical drainage, local antibiotic irrigation, and close collaboration with infectious disease specialists, is essential for achieving optimal clinical outcomes