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ARTICLES
Year : 1985  |  Volume : 33  |  Issue : 2  |  Page : 125-127

Recurrent cavernous sinus thrombosis with bilateral orbital cellulitis


Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
P Pillai
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


PMID: 3833737

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How to cite this article:
Pillai P, Ram J, Khurana G S, Jain I S. Recurrent cavernous sinus thrombosis with bilateral orbital cellulitis. Indian J Ophthalmol 1985;33:125-7

How to cite this URL:
Pillai P, Ram J, Khurana G S, Jain I S. Recurrent cavernous sinus thrombosis with bilateral orbital cellulitis. Indian J Ophthalmol [serial online] 1985 [cited 2021 Feb 26];33:125-7. Available from: https://www.ijo.in/text.asp?1985/33/2/125/30837

The complications of cavernous sinus thrombosis are embolisation[l] leading to infec­tion in the lungs, kidneys and brain, menin­gitis[2], cerebral and cerebellar abscesses[3], subdural empyema[4], orbital abscesses[5],[6] and pituitary damage[7]. The ocular complications are ophthalmoplegias, exposure keratitis and corneal ulceration resulting from proptosis and impaired corneal sensation[8], optic neuritis and anterior ischaemic optic neuropathy[9]. The mortality rate has decreased to about 25% in treated cases of septic cavernous sinus thrombosis[10] and blindness to less than 10%[11]. The sequelae of cavernous sinus thrombosis are a variable degree of perma­nent ophthalmoplegia, blindness due to corneal opacities or optic atrophy, or some degree of visual impairment.

We report a case of recurrent cavernous sinus thrombosis who inspite of complica­tions like total bilateral ophthalmoplegia, orbital cellulitis and abscess, and meningitis, showed complete recovery with no sequelae, after treatment.


  Case report Top


C.L. a 20-year old male was admitted to the emergency ward with the history of fever, nausea, vomiting and protrusion of both eyes for the last 2 days. On systemic examination patient was found to be semi­conscious and febrile. There was marked neck rigidity, Kerning's sign was also positive. One day after admission patient developed marked swelling of the eye lids and became unconscious for one day. Patient had a history of having bad a similar attack of fever, vomiting, diplopia with orbital swelling one month back, following a boil in his right nostril, from which he recovered fully after a short course of antibiotics.

On ocular examination, both eyes showed moderate proptosis and marked lid oedema. Ptosis was also present. The con­junctivae showed severe chemosis [Figure - 1]. Corneal sensations were impaired in both eyes. Pupils were dilated and fixed showing no direct or consensual reaction. There was complete restriction of eyeball movements in all directions in both eyes. Retro-ocular resistance was high in both eyes. Fundi were normal.

On investigation, blood culture revealed growth of E. Coli sensitive to Gentamicin and Erythromycin. Cerebrospinal fluid culture was however sterile. X-ray of skull, paranasal sinuses and chest were normal.

The patient was put on six hourly Inj. Gentamicin 60 mgs, Inj. Crystalline Penicillin 20 lass and Ini Dexamethasone 4 m ,,,s intra­muscularly. Two days after admission the patient developed an abscess in the right lower orbital region. About 5-6 ml. of thick yellowish pus was drained through a small external incision. Drainage had to be repeated two more times during the next few days due to rapid reaccumulation of pus. In the left eye drainage of pus was not done. Culture of pus showed growth of Staphy­lococcus aureus, sensitive to Gentamicin and Cotrimoxazole. The latter was also started in full dose. Patient became afebrile within a weak. On discharge after 10 days the patient showed good improvement in his systemic and ocular condition. He was discharged on Tab. Erythromycin Tab Septran and Tab. Prednisolone in tapering doses. Patient reported back after one month with perfectly normal systemic condi­tion. He had diplopia on laevo and dextro­version. On his next visit, however, he had no diplopia, and had a visual acuity 6/6 in both eyes. There was no proptosis and no lid oedema in any of the eyes. Pupils were briskly reacting and fundi were normal. Ocular movements were full in all directions [Figure - 1].


  Discussion Top


Our patient had septic cavernous sinus thrombosis with neuritic involvement of the IIIrd, IVth, Vth and VIth cranial nerves of both sides. The second cranial nerves were however. not involved though there was a pronounced orbital infection. Considering the gravity of all these signs, alongwith the features of meningitis and septicaemiae, it is unusual that the patient showed complete recovery. This could only be attributed to prompt and effective treatment.

Blood culture may be positive in 80% of such cases and Staphylococcus is the respon­sible organism in 90% of the positive cul­tures[3]. Other organisms responsible for cavernous sinus thrombosis are Streptococcus pyogenes 5%, Pneumococcus 1 % and B. Proteus rarely[5],[12]. It is very rare to find E. Coli as a causative organism as in the case. Cerebrospinal fluid cultures are usually negative in these cases[3]. It is interesting to note that pus culture from the orbital abscess revealed Staphylococcus aureus whereas the blood culture showed E. Coli. It is probable that E. Coli was the primary incriminatory organism whereas Staph. aureus was the secondary invader.

The treatment of this condition is prima­rily the use of high doses of antibiotics to which the organism is sensitive. Treatment should be continued for two to three months in order to avoid a relapse. Our case had re-occurrence after the first attack as treat­ment had been omitted early. Steroid therapy is also indicated in cavernous sinus thrombosis under the cover of antibiotics. It prevents circulatory collapse from pituitary insufficiency[13] and may enhance recovery from ophthalmoplegias as in this case.


  Summary Top


A case of recurrent cavernous sinus thrombosis with bilateral total ophthalmo­plegia and orbital cellulitis is reported. The causative organisms were E. Coli and Staphy­lococcus aureus. E. Coli has not been previously reported as a causative organism. The patient developed orbital abscesses in the course of treatment but eventually made a complete recovery and was left with no sequelae of any kind.

 
  References Top

1.
Parson, M., 1967, Post Grad, Med. J. 43 :409.  Back to cited text no. 1
    
2.
Brown, P., 1936, Brit. Med. J. 1 ; 1195.  Back to cited text no. 2
    
3.
Taylor. P., 1957, Brit. J. Ophthalmol. 41: 228.  Back to cited text no. 3
    
4.
Kubik, C.S. and Adams, R.D , 1943, Brain, 66 : 18.  Back to cited text no. 4
    
5.
Price, C.D , Hameroff, S.B., R.D., 1971. South Med. J. 64 : 1243.  Back to cited text no. 5
    
6.
Gupta, M.C., Ahuja, O.P., and Kumar, S., 1970, Ind. J. Med. Sci. 24: 748.  Back to cited text no. 6
    
7.
Williams, E., 1956, Proc. Roy, Soc. Med. 49: 827.  Back to cited text no. 7
    
8.
Duke Elder, S., 1974, System of Ophthalmology, Vol. XIII Part II, Henry Kimpton, London, p, 884.  Back to cited text no. 8
    
9.
Friberg, T.R., and Sogg, PL., 1978, Arch. Ophthalmol. 26 : 3; 453.  Back to cited text no. 9
    
10.
Bassey, O.D., and Elebate, E.A., 1918, West. Afr. Med. J. 17 : 39.  Back to cited text no. 10
    
11.
Shaw, R.E , 1952, Brit. J. Surg. 40 : 40.  Back to cited text no. 11
    
12.
Dhir, B.K., and Rathore, U C., 1964, Ind. J' Med. Assoc. 43 : 399.  Back to cited text no. 12
    
13.
Solomon, DO., Moses, L., and Volk, M., 1962, Amer. J Ophthalmol. 54:1122.  Back to cited text no. 13
    


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