Presentation on theme: "A Case of Eye Pain and Confusion"— Presentation transcript:
1 A Case of Eye Pain and Confusion Daniel G. Murphy, MD, FACEPVice Chair & Medical DirectorMaimonides Medical CenterBrooklyn, New York
2 First ED Visit: Late Friday Night 24 yo female with headache for 2 weeks, worse over the last 2 days104/76, 80, 18, 98.1FRight 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 traumaSmoker 1 PPDSocial drinkerNo hx of headaches, except for last 2 weeksNo allergiesNo meds except ibuprofen and acetaminophen recently – not helpfulWorked as a part-time sales clerk
4 Exam: First VisitAlert, oriented, looked well except for discomfort of headacheFace 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 UpProchlorperazine 10 mg, by vein Acetaminophen 325/Oxycodone 5, orallyCBC, Chem 7, UCG, CT Head without contrast
6 ED Diagnostic Results: Visit 1 WBC count 12.4KCT head reviewed by ED attending and radiology resident as negative
8 ED Disposition: Visit 1 Patient’s 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
11 ED Discrepancy Procedure Patient was contacted by phone and informed of sinus problem on CTPatient went to her PMD that afternoonPMD 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 eyeContinued, worsening right-sided headacheSlept poorly, confused, hallucinating?100/80, 96, 18, 101.9F
13 Morning Exam: 2nd VisitLeft 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 contrastLPID and ENT consults; vancomycin and metronidazole given by veinAdmitted to MICU
17 Afternoon Exam: 2nd Visit Deteriorating mental status.Mild left sided weakness left upper and left lower extremities.
18 ED Admitting Diagnoses Orbital CellulitisMeningitisRule out Cavernous Sinus Thrombosis
19 Septic Dural Sinus Thrombosis Suppurative Intracranial Thrombophlebitis Infected venous thrombosis of cortical veins or sinusesFrom 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 vomitingHypercoagulable statesImmunologic abnormalities, including the presence of circulating antiphospholipid antibodies
21 Septic Dural Sinus Thrombosis Rare; 155 reported cases since 1940Cavernous 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
30 Coronal view of the cavernous sinus Coronal view of the cavernous sinus. Cranial nerve III is the most superiorly situated nerve in the cavernous sinus. Cranial nerves III, IV, and the first two divisions of the trigeminal nerve, V1 and V2, travel in their respective nerve sheaths laterally in the cavernous sinus. Cranial nerve VI travels more medially within the cavernous sinus adjacent to the cavernous carotid artery. PG = Pituitary gland; S = sphenoid sinus; C = cavernous internal carotid artery.
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.
43 ED ManagementAntibiotics: 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?