Occult invasive group A streptococcal infection with rapid progression to pediatric intraorbital abscess: a case report

Invasive Group A Streptococcal (iGAS) infection is relatively rare in pediatric upper respiratory tract infections, but it can breach anatomical barriers to cause deep abscesses. However, iGAS-induced rapid development of intraorbital abscess in children is extremely uncommon. Due to its high occult nature, it is easily overlooked, which may lead to permanent visual loss or even death. A 6-year-old girl was admitted to the hospital with “rhinorrhea and cough for 1 week, accompanied by fever for 2 days”. Upon admission, the pediatrician diagnosed acute tonsillitis and administered amoxicillin-clavulanate potassium for anti-infective treatment. Four hours after admission, the girl developed right eyelid edema and conjunctival congestion. Six hours after admission, obvious proptosis and diminished direct light reflex were noted in the right eye, and the pediatrician immediately initiated a multidisciplinary team (MDT) consultation. Based on the combined findings of orbital computed tomography (CT) and paranasal sinus magnetic resonance imaging (MRI), MDT confirmed the girl to have sinusitis complicated by orbital cellulitis, and that her condition had progressed to the rapidly progressive stage of intraorbital abscess. Subsequent results of blood culture and next-generation sequencing (NGS) both indicated GAS infection. After a comprehensive evaluation of all clinical indicators, the MDT formulated a treatment plan involving endoscopic sinus surgery combined with orbital abscess incision and drainage via a supraorbital eyebrow approach. The girl received 3 weeks of postoperative anti-infective therapy, with her inflammatory markers returning to normal and visual acuity restored. No recurrence was observed during the follow-up examination 6 months later. GAS could break through the lamina papyracea in a highly insidious manner, causing invasive infection of orbital tissues, followed by rapid progression of the infection. Clinical diagnosis and treatment emphasizes the rapid response of the MDT consultation. When the child presents with rapid progression of ocular symptoms, it is recommended to escalate the anti-infective regimen and perform early surgical drainage to improve prognosis. This case provides an important reference for the clinical diagnosis and treatment of severe orbital infections caused by iGAS in children.