Meningitis with cranial polyneuritis and cavernous sinus thrombosis by Borrelia crocidurae: First autochthonous case in Europe

Borrelia crocidurae is endemic in West Africa, where it represents the leading cause of tick-borne relapsing fever (TBRF). TBRF typically presents with high fever and systemic symptoms, followed by recurrent episodes. Neurological complications may occur during febrile relapses. B. crocidurae is considered the most neurotropic agent of TBRF and is associated to severe neurological manifestations i.e. meningitis and encephalitis. To date, European cases of B. crocidurae infection have been reported in travelers returning from endemic areas. We report the first autochthonous case in Europe of B. crocidurae infection, presenting as meningitis with cranial polyneuritis and cavernous sinus thrombosis that were not preceded by classic febrile recurrences.

Septic thrombosis of cavernous sinus extended to the ipsilateral internal jugular vein and transversal sinus with favorable outcome: Clinical and radiological features of a Lemierre syndrome

An 86-year-old patient was hospitalized for fever and left acute orbital syndrome (red eye with moderate visual impairment, chemosis, ophthalmoplegia without proptosis, or any fundus involvement). CT scan showed superior ophthalmic vein and cavernous sinus enlargement complicating ipsilateral sphenoidal sinusitis. Magnetic resonance imaging (MRI) demonstrated the left cavernous sinus thrombosis extended to the ipsilateral jugular vein and transversal sinus (Lemierre syndrome). Intravenous broad-spectrum antibiotics and curative anticoagulation were prescribed. Blood cultures allowed the identification of Streptococcus intermedius and Staphylococcus warneri species. Evolution was favorable and the patient was discharged 3 weeks after. Antibiotics and anticoagulation were carried out for a total duration of 4 and 12 weeks, respectively. Lemierre syndrome is a potentially life-threatening emergency rarely encountered; thus, ophthalmologists should be cognizant of clinical and radiological features. Broad-spectrum antibiotics are the mainstay of treatment. Curative anticoagulation may be added if no blood coagulation disorder nor bleeding on neuroimaging has been identified.

[Septic thrombus of the cavernous sinus]

The present review was designed to represent modern views of the problem of etiopathogenesis, clinical features, diagnostics, and treatment of septic thrombus of the cavernous sinus with special reference to the currently available methods for the detection and management of this condition.

Intracranial Infectious Aneurysm in Orbital Cellulitis

Infectious intracranial aneurysm and cavernous sinus thrombosis are rare complications of orbital cellulitis. We report the case of a 46-year-old male presenting with sinusitis and orbital cellulitis complicated by the development of an orbital mass. Following orbitotomy with debulking, the patient underwent bony orbital decompression for increasing proptosis postoperatively. While his exam stabilized, the patient developed complete ptosis and extraocular motor palsy in the contralateral eye after undergoing bilateral sinus debridement. Imaging was notable for the presence of a pseudoaneurysm of the internal carotid artery, which was treated with a stent. This report demonstrates rare complications of orbital cellulitis. These patients should be monitored carefully with noninvasive imaging studies, such as cerebral angiography, for early detection of vascular abnormalities that can progress rapidly.

Bilateral cavernous sinus thrombosis following community-acquired methicillin-resistant staphylococcus aureus infection: a case report and review of the literature

OBJECTIVES

We describe a case of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infection leading to bilateral cavernous sinus thrombosis (CST) and subsequent left eye blindness in a previously healthy, immunocompetent woman. A secondary objective is to document all published cases of MRSA induced CST.

DATA SOURCE AND STUDY SELECTION

To identify all relevant publications on MRSA-induced CST in adults.

RESULTS

Seven publications were included in this review describing patients age 19 or older. Together, with the case included in this publication, a total of 8 cases of MRSA induced CST have been documented since 2003. Of interest, to our knowledge this is the first reported case of CA-MRSA CST temporally associated with nasal H1N1 vaccination.

CONCLUSION

In selecting empiric antibiotic coverage for septic CST, the practitioner should use antibiotics that are active against CA-MRSA to help prevent morbidity and mortality.

Bilateral septic cavernous sinus thrombosis following the masticator and parapharyngeal space infection from the odontogenic origin: a case report

Neglect of odontogenic infections can have serious consequences. If they spread through fascial planes and intracranially they can cause an abscess, orbital cellulitis, and eventually cavernous sinus thrombosis. The authors report a case of rapid progressive bilateral orbital cellulitis and cavernous sinus thrombosis that originated from dental caries. Septic cavernous sinus thrombosis is a medical emergency. Early recognition and prompt treatments direct to the underlying sources of infection are crucial. Broad-spectrum intravenous antibiotics are the mainstay of treatment to reduce morbidity and mortality from this lethal condition. Management should be based on early diagnosis and prompt management with intravenous broad-spectrum antibiotics and surgical intervention.

Cavernous sinus thrombosis secondary to allergic fungal sinusitis

Cavernous sinus thrombosis (CST) is a rare and serious complication secondary to invasive fungal sinusitis, but rarer still in cases of allergic fungal sinusitis. Current recommendations for cavernous sinus thrombosis are controversial, especially regarding anticoagulation, secondary to the rarity of the diagnosis. Early surgical debridement and intravenous antibiotics are crucial to prevent mortality and decrease morbidity. Because thrombosis is thought to be caused by a bacterial superinfection, which follows a response to Aspergillus, antifungals may not be necessary. Despite the controversy, most physicians opt to treat with anticoagulation.

Septic cavernous sinus thrombosis with bilateral secondary orbital infection

Cavernous sinus thrombosis may occur as a secondary threatening condition to spread from local or distant foci of infection. We report a case where secondary retrograde spread occurred to both the ipsilateral and contralateral orbits with very different clinical manifestations. To our knowledge such spread is unreported. The case highlights the difficulty in recognising orbital collections when venous engorgement secondary to a cavernous sinus thrombosis coexists and demonstrates how the prognosis has been improved through antibiotics, anticoagulation and timely surgical intervention.

Septic cavernous sinus thrombosis: an unusual and fatal disease

BACKGROUND

Septic cavernous sinus thrombosis (CST) is a rare and fatal disease. Clinical presentations in the early stage are nonspecific, and the sensitivity of cranial axial computed tomography (CT) with thick section is low. This study analyzed the clinical manifestation and neuroimaging findings in patients with septic CST in a medical center in Taiwan.

METHODS

This retrospective case series included nine patients with septic CST who had typical symptoms and clinical course, evidence of infection, and imaging studies which demonstrated cavernous sinus lesion, and who were treated between 1995 and 2003 at National Taiwan University Hospital.

RESULTS

Seven (77.8 %) patients were more than 50 years old. Five (55.6%) had diabetes, and three (33.3%) had hematologic diseases. All cases were associated with paranasal sinusitis. The most frequent initial symptom was headache (66.7%), followed by ophthalmic complaints (diplopia or ophthalmoplegia, 55.6%; blurred vision or blindness, 55.6%), and ptosis (44.4%). Initial cranial images failed to identify CTS in all patients. Subsequent magnetic resonance imaging (MRI) or coronal contrast-enhanced CT (CECT) with thin section confirmed the diagnosis. Fungi were the most common pathogens (55.6%). The inhospital case-fatality rate was high (44.4%).

CONCLUSION

Due to the high case-fatality rate and low yield rate of blood cultures, fungal CST should be suspected in an immunocompromised patient with ophthalmic complaints that progress from one eye to the other. Coronal thin-section CECT may be a useful alternative to MRI as a diagnostic modality for this condition.

Cavernous sinus anatomy as a basis for interpretation of the clinical picture and radiological investigations in a case of Entomophthorales infection

Several cranial nerves traverse the cavernous sinus producing the typical symptom complex seen during cavernous venous sinus thrombosis in Mucorales infection. Fungi of the order Entomophthorales display different pathological and histological characteristics although belonging to the same class of fungi. A case is presented, wherein the anatomy of the cavernous sinus forms the basis in explaining the presenting symptoms of a patient with Entomophthorales infection. The anatomical explanation for the presenting neurological symptoms is confirmed by radiological investigations and further supports the diagnosis of Entomophthorales infection.

Bilateral blindness from orbital cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus

PURPOSE

To describe bilateral blindness resulting from infection with community-acquired methicillin-resistant Staphylococcus aureus (MRSA).

DESIGN

Observational case report.

METHODS

A 44-year-old man developed proptosis, ptosis, ophthalmoplegia, and no light perception vision after attempting to lance a nasal pustule. A nasal culture grew MRSA. Imaging showed bilateral orbital cellulitis, pansinusitis, and cavernous sinus thrombosis. The right fundus showed severe ischemia, but the left fundus was essentially normal.

RESULTS

Despite initiation of appropriate antibiotics early in the course of infection, the patient lost sight in both eyes. Surgical drainage of the paranasal sinuses and use of intravenous corticosteroids and heparin led to the resolution of orbital cellulitis.

CONCLUSIONS

MRSA orbital cellulitis can progress to irreversible blindness despite antibiotic treatment. A new, community-acquired clone of this organism has exhibited increased potential for tissue invasion.

L’imagerie dans la mucormycose rhinocérébrale

PURPOSE

Rhinocerebal mucormycosis is a rare life threatening fungal infection observed in immunocompromised patients. We report six cases of patients with rhinocerebral mucormycosis confirmed histologically. Our study confirms the necessity of early diagnosis when clinical and CT findings are suggestive.

MATERIALS AND METHODS

This is a retrospective study including 6 diabetic patients (3 women and 3 men) aged from 28 and 63 years. Five patients had ethmoiditis evolving for a few days (3 to 5 days), and one patient was in an ketoacidotic coma and had a severe infectious syndrome with purulent rhinorrhea evolving for 4 days. All of our patients underwent computed tomography (CT) scan of the paranasal sinuses. MRI was performed in two patients with neurological findings.

RESULTS

Unilateral ethmoido-maxillary sinusitis was noted in 5 cases. Only one case of pansinusitis was found. All patients presented orbital involvement. Cerebral involvement was noted in 4 cases (cerebral venous thrombosis: 2 cases; abscess: 2 cases; cerebral ischemia: 2 cases). The diagnosis of mucormycosis was based on endonasal biopsy. When available, MRI allowed a more precise evaluation of the orbital and cerebral extension.

CONCLUSION

Mucormycosis is an opportunist mycosis due to mucoralis fungus. It is very invasive with a highly aggressive potential in diabetic or immunocompromised patients. Imaging study particularly CT scan, plays an important role in diagnosis especially to evaluate cerebral extension.

Aspergillus granuloma of the cavernous sinus: magnetic resonance imaging with pathologic correlation

This case illustrates the correlation between Magnetic Resonance Imaging (MRI) and the pathological findings in a case of cavernous sinus (CS) aspergilloma.

Septic cavernous sinus thrombosis due to Streptococcus constellatus infection

Adult septic cavernous sinus thrombosis (CST) due to Streptococcus constellatus infection has not been reported. We report a case of CST due to S. constellatus in a 39-year-old man who had typical presentations of septic CST including headache, fever, and ophthalmoplegia, with an evolving course for 10 days before he was sent to our emergency room. Cranial magnetic resonance imaging (MRI) study revealed CST, which was confirmed by cerebral angiography study. Multiple positive blood cultures grew viridans streptococci and further species identification with conventional methods, API-20 STREPT system analysis, and polymerase chain reaction sequencing of bacterial 16S rRNA revealed S. constellatus. The presence of sphenoid sinusitis in this patient was also demonstrated by cranial MRI study, and the presence of meningitis by meningeal irritation signs and inflammatory cerebrospinal fluid (CSF) findings. Chronic alcohol consumption for more than 10 years was the only predisposing condition to this infection. He had a full recovery after 6 weeks of intravenous penicillin G therapy (24 x 10(6) U/day). Almost complete regression of cavernous sinus lesion and resolution of sphenoid sinusitis were shown on follow-up cranial MRI study about 6 months later.

Bilateral cavernous sinus thromboses and intraorbital abscesses secondary to Streptococcus milleri

PURPOSE

To report the first case of bilateral cavernous sinus thromboses and bilateral intraorbital abscesses secondary to Streptococcus milleri.

STUDY DESIGN

Single interventional case report.

INTERVENTION AND TESTING

The findings of the ophthalmic evaluation, radiographic imaging, medical and surgical intervention, specimen cultures, and clinical course were analyzed.

RESULTS

A 17-year-old female had bilateral proptosis, decreased vision in the left eye, and altered mental status at presentation. An orbital compartment syndrome developed in the left eye and purulent material was present after lateral canthotomy, suggestive of an intraorbital abscess. Magnetic resonance imaging (MRI) scans revealed bilateral cavernous sinus thromboses, and subsequent computed tomographic (CT) scans revealed bilateral intraorbital abscesses in the setting of acute ethmoid and sphenoid sinusitis. Antibiotic treatment and surgical drainage of the orbital abscess and sinuses was performed, and specimen cultures revealed S. milleri. After surgery, the patient experienced hearing loss and a right internal capsule infarct, in addition to complete vision loss in the left eye. A second intraorbital abscess developed in the right eye and was drained surgically. The vision remained 20/20.

CONCLUSIONS

Streptococcus milleri is a virulent organism with a propensity to form abscesses in multiple areas of the body and should be considered as a possible etiologic agent in abscess formation of the orbit and cavernous sinus thrombosis.

Cavernous sinus thrombosis caused by zygomycosis after unrelated bone marrow transplantation

Invasive zygomycosis is a devastating fungal infection occurring as an opportunistic infection after bone marrow transplantation (BMT). Sinusitis can lead to fungal infection in immunosuppressed patients, and cavernous sinus thrombosis, an uncommon condition in immunocompetent patients, typically follows an infection involving the medial third of the face, nose, or paranasal sinuses. Patients undergoing unrelated-donor BMT (UD-BMT) are prone to develop life-threatening infections because of poor recovery of cellular immunity. Despite adequate clinical evaluation and treatment, the prognosis of patients with invasive fungal infections is dismal, especially when intracerebral structures are affected. We describe a case of a patient who underwent an UD-BMT and developed cavernous sinus thrombosis after sinusitis due to zygomycosis. Moreover, he also had disseminated fungal (Zygomycetes and Aspergillus) and viral (cytomegalovirus and adenovirus) infections.

Orbital and periorbital infections

Infections of the orbit and periorbital tissues are not uncommon. Trauma, skin infections, and sinusitis are frequently the underlying cause. Studies have shown changes in epidemiology and pathogens in the last decade. Although classical manifestations are usually present, atypical cases without specific signs and symptoms may confound the diagnosis. A high index of suspicion, aided by ultrasonography, computed tomography, and magnetic resonance imaging, is frequently required for an accurate diagnosis. Prompt diagnosis and treatment may lead to resolution of the infection, thus avoiding ocular sequelae. Orbital infections may spread into the globe, causing endophthalmitis. Some patients may even need an enucleation or evisceration. New materials and techniques may improve the final result of an anophthalmic socket.

Complications of acute sinusitis in children

Acute sinusitis is often a mild, self-limiting disease. However, in some cases, especially among children, sinusitis may become a severe, even life-threatening, disease. To examine the nature of complications of acute sinusitis, we studied the cases of children treated at the Helsinki University ENT Hospital, because of a complication caused by acute sinusitis from January 1997 to September 1998. There were 12 children (4 girls, 8 boys), whose ages ranged from 16 months to 16 years. One child had an epidural abscess, one got meningitis and cavernous sinus thrombosis, five had orbital cellulitis, one of whom lost her vision permanently in one eye, and five had preseptal cellulitis. All the children were treated with intravenous antibiotics and all, except the youngest, were treated with a direct sinus puncture. An operation (intranasal antrostomy, orbital drainage, functional endoscopic sinus surgery or adenoidectomy) was performed on six patients. In the majority of children, acute sinusitis is a mild self-limiting disease. However, severe complications still exist. When a complication of sinusitis is suspected, it is of utmost importance that the child be sent immediately to a hospital for proper diagnosis and treatment.

Cavernous sinus thrombophlebitis in children

Eight Thai patients less than 15 years of age who were diagnosed with cavernous sinus thrombophlebitis at Ramathibodi Hospital, Bangkok, Thailand over the past 30 years were reviewed retrospectively. The predisposing infections and causative microorganisms were similar to previous reports in children and adults. Despite severe neurologic dysfunction during admission, including blindness, there was neither death nor severe permanent deficit found in the majority of the patients. Only one patient experienced mild hemiparesis caused by cerebral infarction, which was secondary to this condition. Early recognition of this condition, the appropriate selection of empirical antibiotic therapy, and the awareness of associated complication were the key factors leading to excellent outcome.