Septic thrombosis of the cavernous sinus secondary to meningitis: case report from a referral hospital in Espirito Santo

Case presentation: Female patient, 1 year and 7 months old, previously healthy, presented cervical adenomegaly, fever, and periorbital edema after receiving MMR vaccine. She evolved with a deviation of the labial commissure to the right, neck stiffness, and bilateral periorbital edema. On hospital admission, she presented normal cranial tomography and infectious cerebrospinal fluid with negative culture. She had a generalized onset of a tonic-clonic motor crisis and evolved with anisocoria (L>R), left hemiparesis and left side hypotonia, ptosis, and left ophthalmoplegia. The blood culture was positive for Sthapylococcus aureus. MRI of the brain was performed, with findings compatible with thrombophlebitis of the cavernous sinuses, associated with thrombosis of the superior ophthalmic veins, right sigmoid sinus, and right internal jugular vein, with areas of ischemic vascular injury predominantly in the parietal lobes bilaterally and epidural collection at the anteromedial margin of the right middle cranial fossa, suggestive of empyema. Anticoagulation was not performed due to the infectious etiology of the condition. An angioresonance of the brain was performed after 20 days of antibiotic therapy and showed signs of thrombosis partially recanalized along the sigmoid sinus and in the bulb of the right internal jugular vein and absence of thrombophlebitis and empyema. She was discharged from the hospital using anticonvulsants. Currently, she is being followed up at the neurology outpatient clinic, with progressive clinical improvement of the left peripheral facial nerve palsy, complete left third cranial nerve palsy, and ophthalmoparesis, in addition to left hemiparesis.

Discussion: Cavernous sinus thrombosis can occur for a variety of causes. When generated by infectious conditions, it is called cavernous sinus septic thrombosis. This is a serious and secondary complication, mainly, to facial infections, sinusopathy, and mastoiditis. Staphylococcus aureus is the main etiologic agent. Headache is the most common initial symptom, in addition to fever, edema and periorbital pain, chemosis, proptosis, eyelid ptosis, visual changes, restriction, and pain in eye movement, among others. Early diagnosis and treatment are extremely important in reducing morbidity and mortality and improving prognosis.

Final comments: Septic cavernous sinus thrombosis is a rare complication of meningitis. It is important to pay attention to the possibility of this situation so that it can be addressed promptly.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
18 September 2023