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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 54-57

Post-Covid cavernous sinus thrombosis with peri-orbital cellulitis, ophthalmoplegia, deep cervical vein thrombosis, sinusitis in a 24-year-old lady: A case report


1 Department of Medicine, Fortis Escorts Hospital, Faridabad, Haryana, India
2 Department of Ophthalmology, Fortis Escorts Hospital, Faridabad, Haryana, India
3 Department of Neurology, Fortis Escorts Hospital, Faridabad, Haryana, India
4 Department of Medicine, Silchar Medical College and Hospital, Assam, India

Date of Submission23-Jul-2021
Date of Acceptance27-Jul-2021
Date of Web Publication05-Oct-2021

Correspondence Address:
Dr. Dwijen Das
Department of Medicine, Silchar Medical College and Hospital Silchar, PO—Ghungoor, Silchar Dist., Cachar 788014, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajoim.ajoim_15_21

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  Abstract 

A 24-year-old female presented with blurring of vision, chemosis, protrusion of eyeball, restriction of movements of right eye, numbness over the right side of the face with severe headache, stiffness of neck, and fever of 2 days duration. She gives a history of recent Covid-19 infection 3 weeks back. She was treated symptomatically and recovered fully. On examination, there was proptosis, chemosis, third, fourth, fifth, and sixth nerve palsy on the right side, and nuchal rigidity. She was started on broad spectrum antibiotics, analgesics, anticoagulant, and prophylactic antifungal thinking in line of post-Covid orbital cellulitis or mucormycosis. Her investigations revealed raised total leucocyte count and erythrocyte sedimentation rate with normal ultrasound abdomen and chest X-ray. Blood culture and culture of nasal swab and oral cavity for fungus were sterile. Contrast-enhanced magnetic resonance imaging brain, orbit, and sinus showed proptosis, myofascial edema, superior ophthalmic vein thrombosis, right cavernous sinus and deep cervical vein thrombosis, sphenoid and bilateral ethmoid sinusitis with narrow lumen of the internal jugular vein. She responded very well to the treatment. Her inflammatory parameters came down drastically and clinically, she started opening her eyes and ophthalmoplegia subsided within a week. By the 10th day she was asymptomatic. Repeat MRI showed reduction of proptosis, myofascial edema with partial recanalization of right superior ophthalmic vein, right cavernous sinus, and right deep cervical vein. She was discharged on injectable anticoagulant and antibiotics for another 10 days.

Keywords: Blurring of vision, chemosis, post-Covid patient


How to cite this article:
Thakuria J, Kumar A, Gupta R, Shira JD, Das D. Post-Covid cavernous sinus thrombosis with peri-orbital cellulitis, ophthalmoplegia, deep cervical vein thrombosis, sinusitis in a 24-year-old lady: A case report. Assam J Intern Med 2021;11:54-7

How to cite this URL:
Thakuria J, Kumar A, Gupta R, Shira JD, Das D. Post-Covid cavernous sinus thrombosis with peri-orbital cellulitis, ophthalmoplegia, deep cervical vein thrombosis, sinusitis in a 24-year-old lady: A case report. Assam J Intern Med [serial online] 2021 [cited 2021 Dec 3];11:54-7. Available from: http://www.ajimedicine.com/text.asp?2021/11/2/54/327544


  Introduction Top


Cavernous sinus thrombosis was first described by Duncan in the year 1821 from anatomo-pathological point of view, later by Bright who was the first to describe from clinical point of view.[1] It is a life-threatening medical emergency with 100% mortality without treatment and 30% mortality in patients who received treatment.[2]

Here we present a case diagnosed with cavernous sinus thrombosis in a post-Covid patient.


  Case Report Top


A 24-year-old female presented in medicine OPD, with blurring of vision, chemosis, protrusion of eyeball, and restriction of movements of right eye. The patient also had numbness over the right side of the face with severe headache and stiffness of neck and fever for 2 days. She gives a history of recent Covid-19 infection 3 weeks back. She did not receive Covid vaccine. On examination, there was proptosis, chemosis, third, fourth, fifth, and sixth nerve palsy on the right side and nuchal rigidity [Figure 1]. Thinking in line of orbital cellulitis/mucormycosis after Covid-19 stage, she was started on broad spectrum antibiotics, analgesics, anticoagulant, and prophylactic antifungal. Her blood tests revealed total leucocyte count of 20.7×109/L, erythrocyte sedimentation rate of 140, normal platelet count, C-reactive protein 165, serum iron 40 mcg/dL, transferrin saturation 8%, serum ferritin 426 ng/mL, normal urine analysis, serum protein 7.4 g/dL, serum albumin 4.0 g/dL, normal lipid, normal protein C and S level, and her ultrasound whole abdomen and chest X-ray were normal. Blood culture was sterile, and culture from oral cavity and nasal swab for fungus/mucormycosis was sterile. Contrast-enhanced magnetic resonance imaging (CEMRI) brain, orbit, and sinus showed proptosis, myofascial edema, superior ophthalmic vein thrombosis, right cavernous sinus and deep cervical vein thrombosis/filling defects, sphenoid and bilateral ethmoid sinusitis with narrow lumen of the internal jugular vein [Figure 3][Figure 4][Figure 5][Figure 6]. There were no bony erosions. Ophthalmologist, ENT, and Neurology consultations were taken and management modified accordingly. Patient’s attendant was explained about the need of nasal endoscopy and biopsy but they refused. She responded very well to the treatment. Her fundus examination, intraocular pressure, and vision were normal throughout the treatment course. Her inflammatory/infective parameters came down drastically and clinically, she started opening her eyes, and ophthalmoplegia subsided within a week [Figure 2]. By the 10th day she was asymptomatic, there was no pain, stiffness of neck, headache, or restriction of eye movements, and her pupils were symmetrical bilaterally. Numbness over her face also subsided. Repeat MRI was planned which showed reduction of proptosis, myofascial edema with partial recanalization of right superior ophthalmic vein, right cavernous sinus, and right deep cervical vein [Figure 7][Figure 8][Figure 9]. She was discharged on injectable anticoagulant and antibiotics for another 10 days (total therapy 21 days).
Figure 1: Peri-orbital swelling, proptosis, and chemosis

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Figure 2: Patient’s eye after 1 week of treatment

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Figure 3: CEMRI of sinus showing ethmoid and sphenoid sinusitis

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Figure 4: CEMRI of brain (coronal section) showing cavernous sinus thrombosis and narrowed internal carotid artery

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Figure 5: MRI of brain and orbit showing thrombosis of superior ophthalmic vein

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Figure 6: MRI orbit showing proptosis and peri-orbital swelling

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Figure 7: MRI of brain (coronal section) showing partial recanalization of cavernous sinus

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Figure 8: MRI of brain and orbit showing partial recanalization of superior ophthalmic vein

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Figure 9: MRI of orbit showing reduced peri-orbital swelling of the same patient

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  Discussion Top


Cavernous sinus has been termed as the “anatomic jewel box” because of its close relationship with important structures of the brain. The structures passing through the lumen of cavernous sinus are internal carotid artery, sympathetic plexus, and sixth cranial nerve, whereas the third nerve, fifth nerve (ophthalmic branch and trigeminal branch), and fourth nerve traverse the outer layer of the lateral wall of cavernous sinus.

Cavernous sinus thrombosis mostly occurs as a result of spread of infection such as complicated facial infections, sinusitis, orbital cellulitis, pharyngitis, otitis media, mastoiditis, or following surgeries, but may also occur due to non-infectious causes such as trauma, surgery, and pregnancy.

In the background of thrombophilic disorders, the mechanism behind cavernous sinus thrombosis is considered to be due to embolization of bacteria and other infectious organisms, which led to decreased drainage of facial vein and superior and inferior ophthalmic vein leading to different manifestations. There is also communication between right and left cavernous sinus.[3]

In COVID-19 infection, it has been found in several studies that some patients have a serious hypercoagulable state leading to venous and arterial thrombosis which may lead to death.[4],[5] The mechanism responsible for increased risk of thrombosis is suspected to be due to ACE 2 receptor facilitating the cell entry of SARS-CoV-2, which is expressed on endothelial cells of multiple organ system. Viral infection of endothelial cells causes endothelial inflammation and endothelial damage leading to exposure of Von Willebrand factor, and histological evidence of complement-mediated thrombotic microvascular injury has been demonstrated with Covid-19 infection. This together with cytokine storm contributes to vasoconstriction, inflammation, ischemia, and hypercoagulopathy.[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Tempea V, Gorun G. Cavernous sinus thrombosis. Arch Otolaryngol Head Neck Surg 1959;69:220-3.  Back to cited text no. 1
    
2.
Absoud M, Hikmet F, Dey P, Joffe M, Thambapillai E. Bilateral cavernous sinus thrombosis complicating sinusitis. J R Soc Med 2006;99:474-6.  Back to cited text no. 2
    
3.
Plewa MC, Tadi P, Gupta M. Cavernous Sinus Thrombosis [Updated February 3, 2021]. StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448177/.  Back to cited text no. 3
    
4.
Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.  Back to cited text no. 4
    
5.
Khacha A, Bouchal S, Ettabyaoui A, Haloua M, Lamrani YA, Boubbou M, et al. Cavernous sinus thrombosis in a COVID-19 patient: A case report. Radiol Case Rep 2021;16:480-2.  Back to cited text no. 5
    
6.
Thompson A, Morgan CAM, Smith P, Jones C, Ball HA, Coulthard EJ, et al. Cerebral venous sinus thrombosis associated with COVID-19. Pract Neurol2020;21:75-6.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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