A Severe Case of Septic Cavernous Sinus Thrombosis Caused by a Rare Pathogen

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Cavernous Sinus Thrombosis (CST) is thrombophlebitis in the cavernous sinuses. Before the availability of antibiotics, this dramatic and lethal illness carried a 100% mortality, therefore, the onus is on the clinician to have early recognition of this disease and treatment options, which include antibiotics, anticoagulation, and surgery. Although there have been case reports of CST as a complication of paranasal sinusitis, otitis media, and pharyngitis in pediatric population, literature review reveals few cases of CST in adults causing multi-organ impairment similar to our patient. We report a case of CST causing cranial nerve palsy and internal carotid artery narrowing from ethmoid and sphenoid sinusitis secondary to Group C, Beta Hemolytic Streptococcus. This is a common flora of upper airways and skin and bacteremia is almost always seen in immunocompromised individuals and rarely seen in an immunocompetent patient like ours. CASE PRESENTATION: 36 year old female with no significant past medical history presented to the ED with a three day history of left sided headaches, subjective fevers, diplopia and left periorbital swelling. On exam, she was febrile with left eye proptosis and left lateral gaze palsy. Labs revealed significant leukocytosis with left shift and elevated inflammatory markers. CTA head and neck showed left cavernous sinus thrombosis/thrombophlebitis as well as narrowing of left internal carotid artery with MRI/MRV confirming these findings. Imaging also revealed bilateral complete opacification of sphenoid and ethmoid cells suggestive of severe sphenoiditis and ethmoiditis. She was admitted to ICU and her course was complicated by septic shock and acute hypoxemic respiratory failure requiring pressors and mechanical ventilation as per ARDS protocol. Further septic workup revealed the patient to have beta hemolytic, group C strep bacteremia with nasal culture showing the same speciation. She was started on IV antibiotics and heparin drip in ICU and was later discharged home on oral warfarin and IV ceftriaxone. DISCUSSION: The likely mechanism in our patient is that she initially had ethmoiditis causing orbital inflammation and thrombophlebitis of the ophthalmic vein, which extended posteriorly to cause septic CST. Literature review shows that S. aureus encompasses two-thirds of the cases followed by streptococci, especially pneumococci, but there have been no cases, to our knowledge, of group C beta hemolytic strep causing CST. CONCLUSIONS: Aggressive multidisciplinary approach to management remains key in these patients due to high mortality if there is a delay in early and proper diagnosis. Sinusitis and ethmoiditis are relatively common and a physician should be aware of the potential adverse consequences, especially in the setting of ptosis, proptosis, and external opthalmoplegia. Reference #1: Hiroshi Sakaida, Masayoshi Kabayashi, Ai Ito. Cavernous Sinus Thrombosis: linking a swollen red eye and headache. Lancet 2014: 384: 928 DISCLOSURE: The following authors have nothing to disclose: Hemal Mehta, Anthony Saleh, Ravish Singhal No Product/Research Disclosure Information