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Hospital Medicine Internal Medicine
3-30-2015 Clinical vignette: It was only a zit Noopur Goyal
Charles Pizanis
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Recommended Citation Goyal, Noopur and Charles Pizanis. "Clinical vignette: It was only a zit." (2015). https://digitalrepository.unm.edu/ hostpitalmed_pubs/51
This Presentation is brought to you for free and open access by the Internal Medicine at UNM Digital Repository. It has been accepted for inclusion in Hospital Medicine by an authorized administrator of UNM Digital Repository. For more information, please contact [email protected]. THE UNIVERSITY of NEW MEXICO INTERNAL MEDICINE It Was Only A Zit Noopur Goyal, B.A.; Charles Pizanis, M.D. Albuquerque, NM
Learning Issues • Report a relatively rare condition of septic cavernous sinus Discussion thrombosis. • Cerebral vein thrombosis (CVT) incidence: <1.5 per 100,000 • Identify the need to consider cerebral venous infections associated patients. Higher prevalence is noted in neonates, children, and with pimple popping, alongside awareness of altered mental status young adults. on exam. • In the case of septic cavernous sinus thrombosis, symptoms include: fever, headache, frontal and retro-orbital pain, and diplopia. CN III, IV, VI and V1 and V2 all reside within the cavernous sinus. Case Therefore, ptosis, proptosis, extra-ocular dysmotility, hyperesthesia, and decreased corneal reflex may be noted. • A 45-year-old woman, with a medical history of IV drug use and • Most common bacterial organisms include Staphylococcus aureus (60- chronic hepatitis C virus infection presented to our institution 70%), Streptococcus pneumoniae, gram-negative bacilli, anaerobes. with complaints of painful right eye, periorbital swelling and Figure: MRI brain revealing abnormal contours of the cavernous sinus • Most common fungal organisms include Aspergillus spp., Mucoracae inability to see after recently popping a pimple on her right suggestive of thrombosis (e.g Mucor). cheek. • Complications of CVT: venous infarct, elevated intracranial pressure, cerebral herniation, hemorrhage. • On physical exam, the patient was afebrile and confused. Her Pathophysiology of Septic CVT • Treatment of CVT includes supportive care and anticoagulation IV right eye was swollen with purulent discharge, and she had nerve thrombolytic agents or thrombectomy should be considered if no palsy of CN III-VII on the right side. A 4-mm indurated eschar Direct Transcutaneous clinical improvement. was noted on the right cheek. With the exception of track marks Invasion • Treatment of septic CVT includes antimicrobial therapy for and coarse breath sounds, the remainder of the exam was appropriate infection. normal. Septic Cerebral • Laboratory studies showed leukocytosis with neutrophilia, and an Venous Thrombosis elevated ESR, CRP, and lactate. CT of the head without contrast showed a prominent cavernous sinus. MRI further indicated Conclusion ventriculitis, as well as concern for cavernous sinus thrombus Direct Remote Transmucosal Hematogenous Despite the low incidence of cerebral venous thrombosis, clinicians (see Figure). Blood cultures grew out methicillin-resistant Invasion Spread should consider infected thrombosis in septic patients who present Staphylococcus aureus. with a seemingly harmless pimple flaw. Furthermore, a heightened sense of concern should exist if altered mental status, focal neurologic • During her hospital stay, she underwent canthotomy but References deficits, and other evidence of increased intracranial pressure are deteriorated with subsequent development of septic shock and 1. Coutinho JM, et al. The incidence of cerebral venous thrombosis: a cross-sectional study. Stoke 2012; 43(12)3375-7. 2. Longo, Dan, Editor, et al. (2012). Harrison’s Principles of Internal Medicine (18th ed). Chapter 381. McGraw Hill Publishing. present. This case illustrates the severity of cerebral venous infections multi-organ failure. Five days after presentation, the patient 3. Ebright, John M.D., et al. Septic thrombosis of the cavernous sinuses. JAMA Internal Medicine 2001; 161(22):2671-6. 4. Schaller, B, et al. Cerebral venous infarction: the pathophysiologic concept. Cerebrovascualr Disease 2004: 18(3): 179-88. and secondary thrombosis. passed away. 5. Stam, Jan, M.D,. Ph.D. Thrombosis of the Cerebral Veins and Sinuses. The New England Journal of Medicine 2005: 352: 1791-8.