What is the likely diagnosis and management for an elderly patient with a history of chronic kidney disease (CKD) stage 3, chronic obstructive pulmonary disease (COPD), type 2 diabetes, hypertension, hyperlipidemia, heart failure, atrial fibrillation, and smokeless tobacco use, presenting with left under eye swelling and soreness, left-sided mouth pain, yellow eye discharge, sore and tender area on the left hard palate, and left-sided nasal soreness and tenderness?

Likely Diagnosis: Odontogenic Deep Space Infection with Periorbital Extension

This patient most likely has an odontogenic deep space infection originating from the left hard palate that has extended to involve the periorbital tissues, requiring urgent CT imaging and immediate broad-spectrum IV antibiotics covering oral anaerobes and streptococci.

Clinical Reasoning

Primary Diagnosis: Odontogenic Deep Space Infection

The constellation of findings strongly suggests an odontogenic source:

• Left hard palate tenderness with yellow-white material indicates a primary oral/dental infection focus
• Progressive left periorbital edema and swelling suggests superior extension along fascial planes
• Left-sided nasal tenderness and mucosal edema indicates involvement of adjacent structures
• Left neck tenderness raises concern for descending infection into deep neck spaces
• History of chewing tobacco use (active in bed) significantly increases risk of oral cavity infections and malignancy

Critical Risk Factors in This Patient

This patient has multiple comorbidities that substantially increase infection severity and mortality risk:

• CKD Stage 3 impairs immune function and requires antibiotic dose adjustment 1, 2
• Type 2 diabetes causes impaired leukocyte function, decreased phagocytosis, and poor wound healing in the setting of hyperglycemia 1
• Heart failure (EF 35-40%) increases risk of volume overload with IV fluid resuscitation
• Atrial fibrillation on Eliquis creates bleeding risk that complicates potential surgical intervention
• Multiple chronic conditions substantially increase morbidity and mortality from acute infections 1

Why This is NOT Malignancy (Primary Concern)

While malignancy must remain on the differential given smokeless tobacco use 3, the acute presentation (1 week duration) with purulent material, periorbital edema with yellow discharge, and systemic symptoms (nausea/vomiting) strongly favor acute infection over malignancy, which typically presents more insidiously.

Immediate Management Algorithm

Step 1: Urgent Imaging (Already Planned - Correct Decision)

• CT face/sinuses/neck with IV contrast is the correct imaging modality
• Contrast adjustment for CKD Stage 3: The intravenous administration of radiocontrast can proceed following radiology consensus statements for patients with GFR <60 mL/min/1.73 m² 1
• Critical imaging findings to identify: abscess formation, orbital involvement, cavernous sinus thrombosis, descending necrotizing mediastinitis

Step 2: Immediate Antibiotic Initiation (Do NOT Wait for CT Results)

Start broad-spectrum IV antibiotics immediately covering oral anaerobes and streptococci:

• First-line regimen: Ampicillin-sulbactam 3g IV q6h OR piperacillin-tazobactam 3.375g IV q6h
• Alternative if penicillin allergy: Clindamycin 600-900mg IV q8h PLUS ceftriaxone 2g IV q24h
• Dose adjustment required: All antibiotics must be renally dosed for CKD Stage 3 (GFR 30-59 mL/min/1.73 m²) 2
• Add vancomycin if MRSA risk factors present (prior hospitalization, healthcare exposure)

Step 3: Specialist Consultation (Appropriate Plan)

Multiple specialists required:

• Otolaryngology (ENT): Primary surgical service for deep space neck infections
• Oral-maxillofacial surgery: For odontogenic source control
• Ophthalmology: Urgent evaluation given periorbital involvement to assess for orbital compartment syndrome, vision-threatening complications
• Nephrology consideration: Given CKD Stage 3 and need for nephrotoxic antibiotics 2, 4

Step 4: Critical Monitoring

• Hourly vision checks: Assess for orbital compartment syndrome (vision loss, ophthalmoplegia, proptosis)
• Airway assessment: Deep space infections can compromise airway - monitor for stridor, dysphagia, drooling
• Glycemic control: Target glucose <180 mg/dL to optimize immune function and wound healing 1
• Volume status: Careful fluid management given heart failure with reduced EF 5

Anticoagulation Management

Critical decision regarding Eliquis:

• Hold Eliquis temporarily if surgical drainage is anticipated
• Coordinate with cardiology given atrial fibrillation and IVC filter (suggests prior VTE)
• Risk-benefit analysis: Infection control takes priority over short-term thrombotic risk

Surgical Intervention Criteria

Proceed to surgical drainage if CT shows:

• Defined abscess collection
• Gas in soft tissues
• Orbital subperiosteal abscess
• Descending infection into mediastinum

Surgical approach depends on location: May require combined intraoral drainage, external neck incision, or endoscopic sinus surgery

Common Pitfalls to Avoid

• Delaying antibiotics pending imaging: Infection can progress rapidly to cavernous sinus thrombosis or descending necrotizing mediastinitis - start antibiotics immediately
• Inadequate source control: Antibiotics alone are insufficient if abscess present - surgical drainage is mandatory
• Ignoring vision changes: Orbital involvement requires emergent ophthalmology evaluation and possible urgent decompression
• Standard antibiotic dosing: CKD Stage 3 requires dose adjustment to prevent toxicity 2
• Underestimating airway risk: Deep space infections can cause rapid airway compromise - maintain low threshold for ICU admission and airway protection

Prognosis and Expected Course

• With appropriate treatment: Most odontogenic deep space infections resolve with combined medical-surgical management
• Mortality risk: Significantly elevated in this patient due to multiple comorbidities (diabetes, CKD, heart failure) 5
• Hospital course: Expect 7-14 days IV antibiotics, possible surgical drainage, prolonged hospitalization given comorbidities
• Long-term: Address tobacco cessation (smokeless tobacco increases cardiovascular mortality and morbidity) 3 and optimize chronic disease management 2, 4