A Case of Eye Pain and Confusion

1
A Case of Eye Pain and Confusion

• Daniel G. Murphy, MD, FACEP
• Vice Chair Medical Director
• Maimonides Medical Center
• Brooklyn, New York

2
First ED Visit Late Friday Night

• 24 yo female with headache for 2 weeks, worse
  over the last 2 days
• 104/76, 80, 18, 98.1F
• Right frontal forehead, sharp, non-radiating,
  constant but waxing/waning, worse when she moved.
• () nausea
• (-) fever, photophobia, neck pain or visual
  changes

3
Past Medical/Social History

• No recent trauma
• Smoker 1 PPD
• Social drinker
• No hx of headaches, except for last 2 weeks
• No allergies
• No meds except ibuprofen and acetaminophen
  recently not helpful
• Worked as a part-time sales clerk

4
Exam First Visit

• Alert, oriented, looked well except for
  discomfort of headache
• Face normal, Perrl, EOMI, fundi normal, TMs
  normal, mastoids non-tender, neck supple, motor
  neuro exam normal, normal gait, mental status
  normal

5
ED Therapy and Work Up

• Prochlorperazine 10 mg, by vein Acetaminophen
  325/Oxycodone 5, orally
• CBC, Chem 7, UCG, CT Head without contrast

6
ED Diagnostic Results Visit 1

• WBC count 12.4K
• CT head reviewed by ED attending and radiology
  resident as negative

7
(No Transcript)
8
ED Disposition Visit 1

• Patients pain responded to medications
• Patient discharged with prescription for
  acetaminophen/butalbital/caffeine Fioricet

9
Radiology Over-Read Monday AM(2.5 days since
1st ED visit)

• Opacification of the right ethmoid and right
  sphenoid sinuses with expansion of the sphenoid
  septations toward the left.
• No intracranial disease

10
(No Transcript)
11
ED Discrepancy Procedure

• Patient was contacted by phone and informed of
  sinus problem on CT
• Patient went to her PMD that afternoon
• PMD discharged her with prescription for
  levofloxacin

12
2nd ED Visit Tuesday Morning(3.5 days after 1st
ED visit)

• New onset swelling and severe pain around left
  eye
• Continued, worsening right-sided headache
• Slept poorly, confused, hallucinating?
• 100/80, 96, 18, 101.9F

13
Morning Exam 2nd Visit

• Left peri-orbital edema, erythema, proptosis,
  chemosis, severe pain with EOMs. Left pupil
  reacted to light.
• Ambulated in with normal gait. No obvious motor
  deficits.
• Awake. Followed simple commands, but mildly
  confused, answering slowly or incorrectly, with
  difficulty concentrating.
• () Nuchal rigidity

14
ED Therapy Work Up

• 2 grams ceftriaxone by vein after cultures
• Repeat CT of brain and sinuses with contrast
• LP
• ID and ENT consults vancomycin and metronidazole
  given by vein
• Admitted to MICU

15
(No Transcript)
16
(No Transcript)
17
Afternoon Exam 2nd Visit

• Deteriorating mental status.
• Mild left sided weakness left upper and left
  lower extremities.

18
ED Admitting Diagnoses

• Orbital Cellulitis
• Meningitis
• Rule out Cavernous Sinus Thrombosis

19
Septic Dural Sinus ThrombosisSuppurative
Intracranial Thrombophlebitis

• Infected venous thrombosis of cortical veins or
  sinuses
• From meningitis, subdural empyema, epidural
  abscess, infection in the skin of the face,
  paranasal sinuses, middle ear, mastoid, maxillary
  teeth or neck.
• Iatrogenic cases have been associated with
  rhinoplasty, hip surgery and oral/dental surgery.

20
Non-Septic Dural Sinus Thrombosis

• Dehydration from vomiting
• Hypercoagulable states
• Immunologic abnormalities, including the presence
  of circulating antiphospholipid antibodies

21
Septic Dural Sinus Thrombosis

• Rare 155 reported cases since 1940
• Cavernous Sinus Thrombosis (CST) is the
  predominant subset (62?)
• Fulminant, aggressive disease mortality CST
  30, superior sagittal sinus thrombosis 78
• Morbidity CST 50 cranial nerve deficit 17
  visually impaired

22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30

31
Infected Thrombus Pathogens

• CST Staphylococcus aureus, other gram-positive
  organisms, and anaerobes.
• Lateral Sinus (otitis media and/or mastoid
  infection) Proteus species, Escherichia coli, S.
  aureus, and anaerobes.
• Superior Sagittal Sinus (meningitis or air sinus
  infection) - Streptococcus pneumoniae, S. aureus,
  other streptococci, and Klebsiella species.

32
ED Presentation Superior Sagittal Sinus
Thrombosis

• Headache, nausea and vomiting, confusion, and
  focal or generalized seizures.
• Rapid development of stupor and coma.
• Weakness of the lower extremities with bilateral
  Babinski signs or hemiparesis is often present.

33
ED Presentation Transverse Sinus Thrombosis

• Headache and earache.
• Gradinego's syndrome otitis media, sixth nerve
  palsy, and retro-orbital or facial pain.
• Sigmoid sinus and internal jugular vein
  thrombosis may present with neck pain.

34
ED Presentation Cavernous Sinus Thrombosis

• Sinusitis, midface infection for 5-10 days.
• Fever, headache, malaise, retro-orbital pain and
  diplopia, which generally precede..
• Ptosis, proptosis, chemosis, eyelid edema,
  peri-orbital edema and extraocular dysmotility
  due to deficits of cranial nerves III, IV, and
  VI.
• Hypo- or hyperesthesia of the ophthalmic and
  maxillary divisions of V, decreased corneal
  reflex. dilated, tortuous retinal veins and
  papilledema.
• Meningeal signs nuchal rigidity, Kernig and
  Brudzinski signs.

35
Diagnostic Studies

• CBC, diff, cultures
• Sinus Films, CT, MR, MR Venography, Venous phase
  cerebral angiogram
• LP

36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
ED Management

• Antibiotics S aureus is the usual cause,
  broad-spectrum coverage for gram-positive,
  gram-negative, and anaerobic organisms also,
  pending cultures.
• Drain primary source of infection, if feasible
  (eg, sphenoid sinusitis, facial abscess).
• Anticoagulation in carefully selected cases of
  septic cavernous-sinus thrombosis, not other
  forms of septic dural-sinus thrombosis.
• Urokinase or rtPA?
• Corticosteroids?

44
Consults

• ENT
• Neurology
• ID
• Intensive Care

45
Outcome of Case

• Day 1 Seizure, worsening deficit, intubated
• Day 2 Heparinized, transient neuro improvement
  then relapse.
• Day 5 Sinuses drained
• Day 6 Brain dead
• Day 19 Demise