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A Case of Eye Pain and Confusion Daniel G. Murphy, MD, FACEP Vice Chair & Medical Director Maimonides Medical Center Brooklyn, New York.

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Presentation on theme: "A Case of Eye Pain and Confusion Daniel G. Murphy, MD, FACEP Vice Chair & Medical Director Maimonides Medical Center Brooklyn, New York."— Presentation transcript:

1 A Case of Eye Pain and Confusion Daniel G. Murphy, MD, FACEP Vice Chair & Medical Director Maimonides Medical Center Brooklyn, New York

2 Daniel Murphy, MD 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 Daniel Murphy, MD 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 Daniel Murphy, MD 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 Daniel Murphy, MD ED Therapy and Work Up Prochlorperazine 10 mg, by vein Acetaminophen 325/Oxycodone 5, orally CBC, Chem 7, UCG, CT Head without contrast

6 Daniel Murphy, MD ED Diagnostic Results: Visit 1 WBC count 12.4K CT head reviewed by ED attending and radiology resident as negative


8 Daniel Murphy, MD ED Disposition: Visit 1 Patients pain responded to medications Patient discharged with prescription for acetaminophen/butalbital/caffeine = Fioricet

9 Daniel Murphy, MD Radiology Over-Read: Monday AM (2.5 days since 1 st ED visit) Opacification of the right ethmoid and right sphenoid sinuses with expansion of the sphenoid septations toward the left. No intracranial disease


11 Daniel Murphy, MD 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 Daniel Murphy, MD 2 nd ED Visit: Tuesday Morning (3.5 days after 1 st 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 Daniel Murphy, MD Morning Exam: 2 nd 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 Daniel Murphy, MD 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 Daniel Murphy, MD


17 Afternoon Exam: 2 nd Visit Deteriorating mental status. Mild left sided weakness left upper and left lower extremities.

18 Daniel Murphy, MD ED Admitting Diagnoses Orbital Cellulitis Meningitis Rule out Cavernous Sinus Thrombosis

19 Daniel Murphy, MD Septic Dural Sinus Thrombosis Suppurative 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 Daniel Murphy, MD Non-Septic Dural Sinus Thrombosis Dehydration from vomiting Hypercoagulable states Immunologic abnormalities, including the presence of circulating antiphospholipid antibodies

21 Daniel Murphy, MD 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










31 Daniel Murphy, MD 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 Daniel Murphy, MD 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 Daniel Murphy, MD 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. ED Presentation: Transverse Sinus Thrombosis

34 Daniel Murphy, MD 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. ED Presentation: Cavernous Sinus Thrombosis

35 Daniel Murphy, MD Diagnostic Studies CBC, diff, cultures Sinus Films, CT, MR, MR Venography, Venous phase cerebral angiogram LP

36 Daniel Murphy, MD







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 Daniel Murphy, MD Consults ENT Neurology ID Intensive Care

45 Daniel Murphy, MD 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

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