Bilateral cavernous sinus thromboses and intraorbital abscesses secondary to Streptococcus milleri

doi:10.1016/S0161-6420(02)01765-7

Ophthalmology

Volume 110, Issue 3, March 2003, Pages 569-574

https://doi.org/10.1016/S0161-6420(02)01765-7 Get rights and content

Abstract

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.

Section snippets

Case report

A 17-year-old previously healthy girl sought treatment at the Massachusetts Eye and Ear Infirmary for acute bilateral periorbital edema and decreased vision in the left eye for 24 hours (Fig 1). She had a 3-week history of headaches and nasal congestion. She failed to improve despite symptomatic therapy with analgesics and decongestants. Her symptoms worsened, and she experienced fever, neck pain and stiffness, and emesis. She was admitted to an outside hospital and started on intravenous

Discussion

Cavernous sinus thrombosis is a rare but potentially fatal complication of sinusitis and orbital cellulitis. Cavernous sinus thrombosis was first described by Bright in 1831 as a complication of epidural and subdural infections.2 Sphenoid and ethmoid sinusitis most often cause cavernous sinus thrombosis secondary to thrombophlebitis of the ophthalmic veins.1 Direct extension of an infected thrombus or dissemination of septic emboli may occur.3, 4 The sphenoid sinus lies in close proximity to

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Repeat imaging demonstrated a new superomedial collection concerning for an abscess, which was drained operatively. As in our patient, microbial analysis revealed Streptococcus milleri.5 Although in the setting of orbital cellulitis, another case report describes a patient with septic SOV thrombosis that developed a peri-SOV orbital abscess despite receiving antibiotic treatment.6
This case report documents a 13-year-old male with bilateral cavernous sinus thrombosis and left superior ophthalmic vein thrombosis secondary to sphenoid sinusitis who subsequently developed peri-venous orbital abscesses.
Although the patient initially improved clinically with intravenous antibiotic therapy and therapeutic anticoagulation, his symptoms returned and repeat imaging demonstrated two well-circumscribed, rim-enhancing lesions in the left orbit concerning for abscesses. Surgical intervention revealed that these purulent collections were contiguous with the superior and inferior ophthalmic veins with the superior collection also containing hemorrhagic material. Despite aggressive management, the abscess in the inferolateral orbit recurred, requiring repeat surgical intervention. The patient was ultimately discharged on parenteral antibiotics and anticoagulation, and on outpatient follow-up, there was no evidence of recurrence.
This case report describes a pediatric patient with bilateral cavernous sinus thrombosis who developed the rare complication of multiple peri-venous orbital abscesses despite appropriate treatment with antibiotics. The patient's complex clinical course highlights the importance of prompt repeat imaging and possible surgical intervention upon clinical changes, especially in patients with infections from the Streptococcus milleri group.
Cavernous sinus thrombosis during pregnancy
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Direct signs of CST include expansion of cavernous sinus, convexity of the normally concave lateral wall, abnormal irregular filling defects and asymmetry. Indirect signs may be the dilatation of the superior ophtalmic vein, exophtalmos and thrombi in the veins and cavernous sinus tributaries [4,11]. MRI can detect all stages of thrombus formation.
Cavernous sinus thrombosis (CST) represents a rare but devastating disease process that may be associated with significant long-term patient morbidity or mortality. Rapid diagnosis and aggressive medical and surgical management are imperative for patients with CST. We present the case of a 24-year-old pregnant woman with intraorbital abscess and CST secondary to Streptococcus milleri. Surgical intervention included orbital abscess drainage and dental extraction, medical therapy included intravenous antibiotic, heparin, and methylprednisolone and an elective cesarean section was performed. The latter was the key point to resolution the disease.
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Cultures from surgical specimens provided speciation information in 7 of our 9 patients (78%). Patients younger than 9 years of age usually have abscesses caused by a single organism, whereas older children have a higher frequency of polymicrobial infections and are more likely to harbor anaerobes.4 Overall, the most common organisms implicated in CST in the literature are Staphylococcus aureus and Streptococcus species.5
To review the causes, treatment, and outcomes of cavernous sinus thrombosis (CST) in children.
The medical records of children (<18 years of age) diagnosed with thrombophlebitis of an intracranial venous sinus were reviewed to identify cases of CST presenting to Children’s Hospital Colorado from January 2000 through January 2013. Cases were evaluated for etiology, symptoms, imaging characteristics, treatment, and outcomes.
A total of 110 children with a venous thrombus of an intracranial sinus were included. Of these, 9 had a CST. All cases were confirmed by magnetic resonance imaging. All 9 had sinusitis, 4 had orbital involvement, and 1 resulted from a nasal septal abscess. Eight cases presented with ophthalmoplegia, and 5 presented with decreased vision. Every patient underwent sinus surgery: 4 underwent orbitotomy for abscess drainage, and 1 required bilateral exenteration. Cultures were inconclusive in 2 cases, and 2 cases were culture positive rhino-orbital mucormycosis. There was 1 case of methicillin-resistant Staphylococcus aureus. Of the 9 cases, 4 returned to normal vision and ocular motility; 5 had permanent ophthalmoplegia and vision loss. There were no cases of mortality.
CST is a rare complication of orbital and sinus disease. High clinical suspicion, early neurologic imaging, and a multidisciplinary approach to management are key factors in reducing morbidity and mortality from CST in children.
Periocular Infections
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2014, Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases
Cavernous sinus thrombosis as a result of a fungal infection: A case report
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Before the advent of antibiotics, the mortality rate was as high as 100%, and it is now as low as 20%.6,8,10 The most common organisms isolated from these patients are staphylococcal and streptococcal species.1,5,7 Our case presents an unusual finding of CST due to aspergillosis.
Cavernous sinus thrombosis (CST) is a rare disease with the potential for significant morbidity and even death. Rapid diagnosis and aggressive medical and surgical management are imperative for patients with CST. The cause may be aseptic or infectious. When the cause is infectious in nature, it is most commonly from a bacterial origin. However, we present the case of a 57-year-old man with a fungally related CST that ultimately led to his death.

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Bilateral cavernous sinus thromboses and intraorbital abscesses secondary to Streptococcus milleri☆

Abstract

Purpose

Study design

Intervention and testing

Results

Conclusions

Section snippets

Case report

Discussion

Ophthalmology

Ophthalmology

Surv Ophthalmol

The pathogenesis of orbital complications in acute sinusitis

Laryngoscope

Thrombophlébite du sinus caverneux stratégie diagnostique

J Neuroradiol

Suppurative intracranial complications of sinusitis

Laryngoscope

Septic cavernous sinus thrombosis [editorial]

Aust J Ophthalmol

Intracranial Pyogenic DiseasesA Pathological and Clinical Study of the Pathways of Infection from the Face, the Nasal and Paranasal Air-Cavities

Potential sources for orbital cellulitis

Int Ophthalmol Clin

Acute severe irreversible visual loss with sphenoethmoiditis—‘posterior’ orbital cellulitis

Arch Ophthalmol

Microsurgical anatomy of the sellar region

J Neurosurg

Orbital complications resulting from lesions of the sinuses

Ann Otol Rhinol Laryngol

Inflammatory diseases

Septic thrombosis of the dural venous sinuses

Medicine (Baltimore)

The prognosis and treatment of cavernous sinus thrombosis. Review of 878 cases in the literature

Ann Otol Rhinol Laryngol

Mechanisms of visual loss in severe proptosis

Ophthal Plast Reconstr Surg

Orbital compartment syndromes following trauma

Adv Ophthalmic Plast Reconstr Surg

Space-occupying orbital lesionscan critical increases in intraorbital pressure be predicted clinically?

Laryngoscope

Antibiotic choice in acute and complicated sinusitis

J Laryngol Otol

The role of anticoagulation in cavernous sinus thrombosis

Neurology