JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Septic Cerebral Venosinus Thrombosis Secondary to an Odontogenic Infection
CASE DESCRIPTION
A 69-year-old man with a history of stroke without residual deficits, peripheral artery disease, hyperlipidemia, and prostate cancer was transferred from an outside facility for management of a right-sided odontogenic infection. The patient reported right jaw pain for nine days. Over the preceding three days, the patient developed fever, headaches, blurry vision, mid-facial pain and swelling around the eyes. Physical exam revealed right mandibular pain and swelling, bilateral chemosis, impairment of right eye abduction, and vertical gaze (Figure 1). Laboratory studies revealed a leukocytosis and increased band forms. Blood cultures were positive for gram positive cocci. Cerebrospinal fluid analysis demonstrated 405 white blood cells with eighty- nine percent segmented neutrophils. Computer tomography (CT) of the head and sinuses with intravenous contrast revealed a right multi-loculated mandibular abscess, paranasal sinusitis, and right internal jugular thrombus. Magnetic resonance imaging (MRI) of the brain demonstrated findings consistent with meningitis, a small right-sided subdural empyema and partial thrombosis of bilateral superior ophthalmic veins and cavernous sinus. Magnetic resonance venogram (MRV) revealed a right internal jugular and sigmoid sinus thrombosis. Final blood cultures recovered Streptococcus gordonii, Streptococcus intermedius, Peptostreptococcus anaerobius, and Mycobacterium mucogenicum.
Hongvan Le, MD; Shane Prejean, MD; Madeleine Heck, MD
BACKGROUND Cerebral venosinus thrombosis (CVT) is anuncommon, potentially fatal disease that is more common in young adults and children. Thrombophilia, elevated estrogenic states, and infections are the most common risk factors in patients who develop CVT. CASE A 69-year-old man with a right-sided odontogenic infection presented with fever, headache, opthalmoplegia, and periorbital swelling. Imaging revealedevidenceofmeningitis and thrombosis of bilateral ophthalmic veins, the cavernous sinus, right internal jugular vein, and sigmoid sinus. The patient was treated with empiric antibiotic therapy and unfractionated heparin. He recovered with only mild impairment in right eye abduction. DISCUSSION Early diagnosis and prompt treatment of CVT is vital in reducing the associated morbidity and mortality. Unfractionated or low molecular weight heparin may be safely used in CVT patients. Thrombolytic therapy is an option in clinically severe cases. Treatment also includes addressing the underlying cause and management of early complications.
INTRODUCTION
Cerebral venosinus thrombosis (CVT) is an uncommon, potentially fatal disease. Though initially thought to be rare, its incidence has increased with the advancement of modern imagingmodalities.While CVT affects all age groups, it generally occurs in young adults with a mean age of 39. 1 The most common risk factors identified in 624 CVT patients include underlying thrombophilia, elevated estrogenic states, and infections. 1 Patients with prothrombotic conditions, both genetic and acquired, are at increased risk of developing CVT. These prothrombotic conditions include but are not limited to Factor V Leiden mutation, protein C, S, or antithrombin deficiencies, antiphospholipid antibody, and hyperhomocysteinemia. 1-3 High estrogenic states due to oral contraceptive use, pregnancy and the immediate postpartum period are the most common predisposing factors in CVT cases amongst women. 1, 2 Infection is also a major risk factor and a frequently documented cause of CVT. Infections of the ear, sinus, mouth, head and neck are responsible for over 60% of CVT cases of infectious origin. 1 Factors such as malignancy, injury ,and mechanical precipitants have been identified in less than 20% of CVT cases combined. 1 Notably, CVT patients often have more than one risk factor. 1 If CVT is clinically suspected, workup for predisposing factors and etiologies should be pursued.
FIGURE 1: Chemosis and Abducens Nerve (CN VI) Palsy. Significant peri-orbital swelling and scleral edema is seen (Top). Right sixth nerve paralysis is demonstrated by the absence of right eye abduction when the patient was asked to look to the right (Bottom).
J La State Med Soc VOL 169 MARCH/APRIL 2017 33
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