A Case of Eye Pain and ConfusionA Case of Eye Pain and Confusion

Daniel G. Murphy, MD, FACEP

Vice Chair & Medical Director

Maimonides Medical Center

Brooklyn, New York

Daniel Murphy, MD

First ED Visit: Late Friday NightFirst 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

Daniel Murphy, MD

Past Medical/Social HistoryPast 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

Daniel Murphy, MD

Exam: First VisitExam: 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

Daniel Murphy, MD

ED Therapy and Work UpED Therapy and Work Up

• Prochlorperazine 10 mg, by vein Acetaminophen 325/Oxycodone 5, orally

• CBC, Chem 7, UCG, CT Head without contrast

Daniel Murphy, MD

ED Diagnostic Results: Visit 1ED Diagnostic Results: Visit 1

• WBC count 12.4K

• CT head reviewed by ED attending and radiology resident as negative

Daniel Murphy, MD

ED Disposition: Visit 1ED Disposition: Visit 1

• Patient’s pain responded to medications

• Patient discharged with prescription for acetaminophen/butalbital/caffeine = Fioricet

Daniel Murphy, MD

Radiology Over-Read: Monday AMRadiology Over-Read: Monday AM(2.5 days since 1(2.5 days since 1stst ED visit) ED visit)

• Opacification of the right ethmoid and right sphenoid sinuses with expansion of the sphenoid septations toward the left.

• No intracranial disease

Daniel Murphy, MD

ED Discrepancy ProcedureED 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

Daniel Murphy, MD

22ndnd ED Visit: Tuesday Morning ED Visit: Tuesday Morning(3.5 days after 1(3.5 days after 1stst ED visit) 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

Daniel Murphy, MD

Morning Exam: 2Morning Exam: 2ndnd Visit 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

Daniel Murphy, MD

ED Therapy & Work UpED 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

Daniel Murphy, MD

Daniel Murphy, MD

Daniel Murphy, MD

Afternoon Exam: 2Afternoon Exam: 2ndnd Visit Visit

• Deteriorating mental status.

• Mild left sided weakness left upper and left lower extremities.

Daniel Murphy, MD

ED Admitting DiagnosesED Admitting Diagnoses

• Orbital Cellulitis

• Meningitis

• Rule out Cavernous Sinus Thrombosis

Daniel Murphy, MD

Septic Dural Sinus ThrombosisSeptic Dural Sinus ThrombosisSuppurative Intracranial ThrombophlebitisSuppurative 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.

Daniel Murphy, MD

Non-Septic Dural Sinus ThrombosisNon-Septic Dural Sinus Thrombosis

• Dehydration from vomiting

• Hypercoagulable states

• Immunologic abnormalities, including the presence of circulating antiphospholipid antibodies

Daniel Murphy, MD

Septic Dural Sinus ThrombosisSeptic 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

Daniel Murphy, MD

Infected Thrombus PathogensInfected 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.

Daniel Murphy, MD

ED Presentation: ED Presentation: Superior Sagittal Sinus ThrombosisSuperior 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.

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: ED Presentation: Transverse Transverse Sinus ThrombosisSinus Thrombosis

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: ED Presentation: Cavernous Cavernous Sinus ThrombosisSinus Thrombosis

Daniel Murphy, MD

Diagnostic StudiesDiagnostic Studies

• CBC, diff, cultures

• Sinus Films, CT, MR, MR Venography, Venous phase cerebral angiogram

• LP

Daniel Murphy, MD

Daniel Murphy, MD

Daniel Murphy, MD

Daniel Murphy, MD

Daniel Murphy, MD

Daniel Murphy, MD

Daniel Murphy, MD

Daniel Murphy, MD

ED ManagementED 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?

Daniel Murphy, MD

ConsultsConsults

• ENT

• Neurology

• ID

• Intensive Care

Daniel Murphy, MD

Outcome of CaseOutcome 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