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A Case of Eye Pain and Confusion

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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

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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

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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

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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 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 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

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25 Schematic axial projection of the cavernous sinus and its venous anastomoses.

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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.

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

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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


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