Cavernous sinus syndrome secondary to thrombophlebitis due to Streptococcus intermedius complicated with vasculitis of the internal carotid artery and brain abscesses
*Correspondencia: Dr. David Alberto Anguizola Tamayo. Servicio de Neurología. Hospital Universitario Galdakao-Usansolo. Barrio Labeaga, s/n. E-48960 Galdakao (Vizcaya).
E-mail: dvanguizola@gmail.com
Introduction. Thrombophlebitis of the cavernous sinus is a severe infectious disease with high mortality and morbidity. It is usually diagnosed at a late stage and requires a number of visits to the emergency department in most cases, and the prognosis is highly dependent on prompt treatment. Despite its severity, evidence regarding treatment with corticosteroids and anticoagulation therapy is scarce and controversial. One of its complications is arteritis, which can be mistaken for medium to large vessel vasculitis, as in this case.
Case report. A 26-year-old female, who visited due to headache and left palpebral oedema. Imaging tests revealed thrombosis in the left cavernous sinus and significant narrowing of the internal carotid artery. The clinical picture was interpreted as secondary to an inflammatory vascular process and treatment with corticosteroids was initiated, with a good response. However, soon afterwards, fever and contralateral palpebral oedema developed. In the blood cultures a growth of Streptococcus intermedius was obtained and thrombophlebitis of the cavernous sinus was diagnosed. Despite initiating antibiotic and anticoagulation therapy, the patient suffered a right hemiplegia secondary to the formation of frontotemporal abscesses. Surgical drainage was performed and the patient progressed well. In the absence of other infectious foci, and due to the oral origin of the germ, a prophylactic multiple exodontia was performed.
Conclusion. Thrombophlebitis should be considered as a diagnostic option both in headaches with ocular symptoms and in medium to large vessel arteritis so that they can be treated in a timely manner.
Caso clínico Mujer de 26 años, que acude por una cefalea y un edema palpebral izquierdo. En las pruebas de imagen se evidencia trombosis del seno cavernoso izquierdo y una estrechez importante de la arteria carótida interna. Se interpreta el cuadro como secundario a un proceso vascular inflamatorio y se inician corticoides, con buena respuesta. Sin embargo, al poco tiempo se presenta fiebre y edema palpebral contralateral. En los hemocultivos se obtiene un crecimiento de Streptococcus intermedius y se diagnostica una tromboflebitis del seno cavernoso. A pesar del inicio de antibióticos y anticoagulación, sufre una hemiplejía derecha secundaria a la formación de abscesos frontotemporales. Se procede al drenaje quirúrgico y la paciente cursa con buena evolución. Ante la ausencia de otros focos infecciosos, y debido a la procedencia oral del germen, se realiza una exodoncia múltiple profiláctica.
Conclusión Se recomienda considerar la tromboflebitis como una opción diagnóstica tanto en las cefaleas con síntomas oculares como en la arteritis de mediano-gran vaso para su tratamiento oportuno.
