Cavernous Sinus Thrombosis, Septic


Step 1: View clinicals

A 26-year-old woman presents with diplopia, since waking up a couple of hours ago. She also complains of a worsening retro-orbital headache which started 3 days ago, and fever since 4 days ago. Self-medication with acetaminophen controlled the fever, but did not relieve the headache. She was diagnosed with type I diabetes mellitus 8 years ago, and is on insulin therapy. Her glycemic control has been suboptimal due to poor compliance. Her most recent HbA1c assay is 7.5%, dating from 1 month ago. Her history is otherwise unremarkable. A random capillary glucose is found to be 306 mg/dL (17 mmol/L).

Step 2: Order all relevant investigations

Complete blood count

Hb: 13 g/dL (11-18) Hematocrit: 40% (35-45) WBC: 18,000/mm3 (4,600-11,000) Neutrophils: 85% Platelets: 250,000/mm3 (150,000-450,000)

Contrast CT Brain

Abnormal filling defects are seen in both cavernous sinuses. There is no evidence of cerebral edema, hemorrhages, or mass lesions.

Blood cultures

Culture reports will be available in 48 to 72 hours.

Lumbar puncture

The cerebrospinal fluid (CSF) sample has a clear appearance. Protein, glucose, and white blood cells are within the reference ranges. No organisms are found upon gram staining.

Step 3: Select appropriate management

Empirical IV antibiotics
Antiepileptic therapy
Endovascular thrombolysis
Drain facial furuncle

Score: ★★☆