A 14-year-old boy presented to the ED with fever, lethargy, and left V2 distribution paresthesias. He had four prior ED visits over the week for constant worsening left jaw pain, for which he was diagnosed with a dental abscess and treated with penicillin.
What is his diagnosis?
Find the diagnosis and case discussion on p. 20.
Diagnosis: Septic Cavernous Sinus Thrombosis
Septic cavernous sinus thrombosis (CST) results from the formation of a blood clot within the cavernous sinus. The disease commonly arises from a contiguous infection within the sinuses, face, nose, or oral cavity. (Int J Sroke 2009;4:111.) CST is rare in the antibiotic era, but it remains a life-threatening disease with 20 to 30 percent mortality requiring emergent treatment.
The cavernous sinus is vulnerable to infection because of the lack of valves in the dural sinuses and the cerebral veins, which allow blood to flow in either direction according to pressure gradients in the vascular system. Staphylococcus aureus continues to be the most commonly identified pathogen, occurring in 60 to 70 percent of patients. Other bacterial pathogens include Streptococcus pneumonia, gram-negative bacilli, and anerobes. Blood cultures are positive in 70 percent of cases. (Pediatr Crit Care Med 2004;5:86.)
The most common clinical symptoms include fever, ptosis, proptosis, chemosis, and cranial nerve palsies occurring in approximately 80 percent of patients. Lethargy, headache, periorbital swelling, and papilledema occur in 50 to 80 percent of cases. Less than 50 percent of patients will demonstrate nuchal rigidity, diplopia, a sluggish or dilated pupil, seizures, and periorbital sensory loss. (Arch Intern Med 2001;161:2671.)
Diagnosis most commonly relies on clinical findings supported by a high-resolution CT or MRI. Findings include enlargement and expansion of the cavernous sinus with lateral wall flattening or convexity and filling defects within the enhancing cavernous sinus and exophthalmos. MRI remains more sensitive than CT, but both modalities can demonstrate false-negative scans early in the course of the disease, requiring the physician to maintain a high degree of clinical suspicion. (Head Face Med 2013:9:9.)
Treatment of CST involves IV antibiotics targeting the most common pathogens and surgical management of the source of infection, including the paranasal sinuses, dental infection, and complicating abscess. No randomized trials have been performed, but retrospective studies suggest a benefit from anticoagulation with heparin. Anticoagulation within seven days of hospitalization for CST may reduce rates of diplopia, unilateral blindness, seizures, and hemiparesis. Typically, patients continue anticoagulation for four to six weeks with warfarin after initial heparin therapy. Mortality has decreased to 20 to 40 percent in the antibiotic era, and 77 percent of patients suffered some long-term sequelae. Prolonged cranial nerve dysfunction, primarily involving cranial nerves III and VI, were most common, occurring in up to 17 percent of patients. Blindness (17%), pituitary insufficiency (2%), and hemiparesis (3%) have also been noted. (Arch Intern Med 2001;161:2671.)
This patient was treated with IV Unasyn and clindamycin. He was taken to the operating room by otolaryngology for endoscopic sinus surgery involving an ethmoidectomy and sphenoidectomy. The patient was anticoagulated with heparin while in the hospital and discharged home on enoxaparin. The patient recovered well with no neurologic deficits or visual disturbances documented in follow-up.
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