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Septic Cerebral Vein Thrombosis and Abnormal Leptomeningitis As a Complication from a Periodontitis in a Hispanic Male: Case Report and Literature Review

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Septic Cerebral Vein Thrombosis and Abnormal Leptomeningitis As a Complication from a Periodontitis in a Hispanic Male: Case Report and Literature Review Elmer Press Case Report J Med Cases • 2013;4(9):598-601 Septic Cerebral Vein Thrombosis and Abnormal Leptomeningitis as a Complication From a Periodontitis in a Hispanic Male: Case Report and Literature Review Sarmad Saida, b, Chad J. Coopera, Haider Alkhateeba, Sucheta Gosavia, Ogechika Aloziea Abstract Introduction Sinus vein thrombosis is a rare form of stroke that results from Cerebral venous thrombosis (CVT) is an uncommon cere- thrombosis of the dural vein sinus. Despite the variety of diagnostic brovascular disease presenting with a remarkably wide procedures and treatment, septic thrombosis of the cavernous sinus spectrum of signs and mode onset [1]. CVT may occur as a can cause significant morbidity and mortality if not diagnosed and complication of infectious or noninfectious processes. Sep- treated as an emergency. The clinical presentation of proptosis that tic thrombosis describes a thrombophlebitic process affect- occurs suddenly accompanied by erythema of the eyelid and limita- ing the cavernous sinus with an infective etiology. Reviews tion of ocular movement should alert the clinician of the possibility of cavernous sinus thrombosis. A 38-year old Hispanic male pre- of large single center series from the pre-antibiotic and early sented with pounding headache, mainly in the occipital region that antibiotic era had documented that infections of the middle began 1 week prior to hospital admission. During the hospitaliza- third of the face were responsible for most cases of SVT. Ap- tion the patient subsequently developed a progressive worsening of proximately 60 to 80% of these nasal furunculosis accounts proptosis, lacrimation and neck pain. The MRI and venography of for the most common cause [2]. Organisms may reach the the brain showed a cerebral venous thrombosis (CVT) with a reac- cavernous sinus from the face by an anterograde route along tive diffuse leptomeningitis. The underlying cause was a chronic the ophthalmic veins, which is connected to the angular dental infection. The patient was treated with course of antibiot- veins, or by a retrograde route along the emissary veins that ics and discharged. A few weeks later the repeated imaging studies are connected to the pterygoid venous plexus. In up to 25 per showed a resolution of the CVT and leptomeningitis. Although rare, cent of cases where a facial furuncle is responsible, it has septic vein thrombosis (SVT) remains a potentially lethal complica- either been previously manipulated by the patient or incised tion of infections that involve the sinuses, face, ears and oral cavity. The early recognition and differentiation from other diseases are by the surgeon [3]. Staphylococcus aureus is the most fre- keys to reducing mortality rates and long-term sequelae. Advances quently cultured organism in these infections accounting for in imaging, especially CT and MRI have contributed substantially 70 %, followed by Streptococcus species at 20 % [4]. to the rapid diagnosis of the condition. Septic thrombosis of the dural venous sinuses is a rare but often catastrophic complication by a variety of infectious Keywords: Periodontitis; Leptomeningitis; Cerebral vein throm- processes. Bacterial meningitis and paranasal sinusitis can bosis be a complication of superior sagittal thrombosis, resulting in an 80 % mortality rate [5]. Septic CVT can occur at any age but typically affects young adults, most commonly in the 3rd decade of life. The incidence is 3 - 4/1,000,000 with 3:1 female predominance [6]. Manuscript accepted for publication July 5, 2013 Early diagnosis can be facilitated by prompt recognition aDepartment of Internal Medicine, Paul L. Foster School of Medicine, of the clinical and radiological findings that are suggestive of Texas Tech University Health Sciences Center, 4800 Alberta Ave, El venous occlusion of the cavernous sinus. The vast majority Paso, Texas, 79905, USA of cases of septic CVT have an acute presentation associated b Corresponding author: Sarmad Said, Department of Internal Medicine, with prominent features of sepsis. The latent period between Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, 4800 Alberta Ave, El Paso, Texas, 79905, USA. symptoms of the predisposing infection and the clinical fea- Email: [email protected] tures of septic SVT varies between one and twenty-one days, but averaged about five to six days in one series [3]. Pyrexia doi: http://dx.doi.org/10.4021/jmc1370w occurs in over 90 per cent of cases, which is usually severe, and may have a ‘picket fence’ pattern suggestive of throm- 598 Articles © The authors | Journal compilation © J Med Cases and Elmer Press™ | www.journalmc.org 599 This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited Said et al J Med Cases • 2013;4(9):598-601 Figure 1. Diffuse supra and infratentorial leptomeningitis and acute thrombosis of the left cavernous sinus, supe- rior petrosal sinus, sigmoid sinus, jugular bulb, and suboccipital vein. bophlebitis. Other features of sepsis may be the presence of Mexico and was given amoxicillin for an unknown reason. tachycardia, vomiting, hypotension, confusion, rigors and Four days before the admission he visited the ER in anoth- comatose [3]. Headache has been reported in about 52 - 90 er hospital and was given NSAIDs and diazepam and was percent and is typically unilateral, with a retro-orbital or discharged home. Over the following two days before the frontotemporal area distribution [7]. admission he experienced progressive lacrimation, eye dis- Impaired vision is uncommon. Nevertheless, visual loss comfort aggravated by eye movement and minimal swelling may be caused by corneal ulceration secondary to propto- around his left eye. He described subjective febrile episodes. sis and loss of the corneal reflex, occlusion of the internal He denied chest pain or shortness of breath. Social history carotid, ischemic optic neuropathy, orbital congestion, toxic was negative for tobacco, alcohol or drug use. No pertinent neuritis of the optic nerve, or embolic phenomena [8]. physical findings noted except minimal left eye proptosis CT and MRI are the primary radiological modali- and lacrimation. Neurological exam revealed a minimally ties used to confirm the diagnosis if suspected on clinical positive Kernig sign. The laboratory findings were positive grounds. The most sensitive investigation of intracavernous for a leukocytosis of 14.81, but otherwise other lab values occlusive defects is venography. Nowadays, cerebral angi- were unremarkable. ography has been reserved for the definitive assessment of A computer-tomography of the brain was done in the intracavernous aneurysms after they have been detected and emergency department. No acute intracranial trauma was monit¬ored using CT or MRI [9]. noted. Multiple attempts to perform a lumbar puncture in the Undoubtedly, antibiotics have the greatest impact on the ER were unsuccessful. Due to the clinical presentation, he prognosis of SVT [10]. Postmortem studies have shown that was started on empiric antibiotics of vancomycin and cef- there is less extensive thrombosis within the cavernous si- triaxone, and an antiviral regimen of acyclovir. A lumbar nuses since the advent of antibiotics [10]. puncture (LP) was ordered and Interventional Radiology We present a case of septic cavernous sinus thrombosis (IR) planned to do this the following day. The next day, it as a complication of a leptomeningitis, which resulted from was noted that there was a progressive bulging and swelling a periodontitis in a Hispanic male patient. of the left eye. On the following day at about 7 A.M. he was unable to open his left eye; at about 11 A.M. he complained about double vision. At this time the neck pain and headache Case Report were constant. The lumbar puncture performed by IR showed WBC of 38 years old right handed, Hispanic male without a signifi- 631/µL, 68% segs, 3% bands, 20% lymphocytes, 9% mono- cant past medical history presented to the ER with a pro- cytes, RBC 30/µL, Protein 99 mg/dL, and Glucose 60 mg/ gressive pounding occipital headache that started almost 1 dL. At this time, the differential diagnosis included menin- week prior to admission. Approximately 2 weeks prior to gitis, cavernous sinus thrombosis or a retro-orbital abscess. admission, he visited his primary care physician in Juarez, Magnetic resonance imaging of brain showed diffuse supra 598 Articles © The authors | Journal compilation © J Med Cases and Elmer Press™ | www.journalmc.org 599 Septic Cerebral Vein Thrombosis J Med Cases • 2013;4(9):598-601 Figure 2. Resolution of abnormal diffuse supra/infratentorial smooth leptomeningeal enhancement. Continued absent flow void and central flow void of left transverse, sigmoid, and jugular vein. and infratentorial leptomeningitis with acute thrombosis of become trapped by the numerous trabeculations within the the left cavernous sinus, superior petrosal sinus, sigmoid si- cavernous sinus [12]. nus, jugular bulb and suboccipital vein (Fig. 1). It was nega- Oral and dental infections were implicated in less than tive for venous infarct, intracranial hemorrhage, midline shift 10 percent of cases of septic CVT in the early antibiotic era, or hydrocephalus. Facial CT was performed and showed a but are now rare [13]. Infections may spread from the maxil- periodontitis in tooth #17 and #18 without destruction
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