Case Presentation: A 20-year-old male presented with a one-week history of high fevers, headaches and nasal congestion, and he was diagnosed with Covid-19. Over the following three days, he developed left eye proptosis, altered mental status and photophobia. Prior to infection, the patient was in good health, did not smoke and had no family history of hypercoagulable disorders. He had an elevated ESR and CRP of 97 mm/hr and 32.5 mg/dl, respectively. The initial CMP revealed a white blood cell count of 16.8 K/L with an absolute neutrophil count of 14.4 K/L. His prothrombin time was increased to 17.7 seconds, but partial thromboplastin time and INR were within normal limits. An MRI showed left-sided post-septal cellulitis and a subperiosteal abscess with concerns of subdural empyema and confirmed the presence of left superior vein and cavernous sinus thrombosis (CST). Blood cultures were drawn, and he was given triple antibiotic ointment with moxifloxacin drops for his eye and started on broad-spectrum IV antibiotics, including vancomycin, cefepime, and metronidazole. A canthotomy was performed, and eye drops were added to reduce intraocular pressure. Over the following days, he was intubated and underwent a craniotomy with subdural empyema evacuation. Argatroban was started and then replaced with oral apixaban. On day 6, he became more responsive and was extubated. Cultures from the empyema showed a polymicrobial infection, and blood cultures were positive for Fusobacterium species. The antibiotic regimen was changed to Meropenem. The patient remained on this antibiotic regimen for six weeks and remained on oral apixaban.
Discussion: Covid-19 is typically associated with fevers, cough and fatigue, but it is also associated with additional complications, such as venous thromboembolism (VTE) due to hypercoagulability (1). Currently, the etiology of hypercoagulability in Covid-19 is not well-understood, but there are three elements of coagulation that seem to be impacted. Infection with Covid-19 causes the release of acute phase reactants and directly invades endothelial cells, which results in injury to these cells (2). As they are damaged, surrounding platelets activate to form clots, increasing the risk of thrombosis (3). Hospitalized patients are typically immobilized leading to blood stasis (1,3). Finally, studies have shown elevations in D-dimer, fibrinogen, and von Willebrand factor in Covid-19 patients, which leads to a hypercoagulable state (1,3,4).Superinfection in patients with Covid-19 can travel through valveless diploic veins into the cavernous sinus. This can progress to the formation of a subdural empyema, leading to additional complications (5). There are multiple reports of patients with Covid-19 having VTEs (6,7). However, this complication is typically found in ICU patients and is usually in the form of deep vein thrombosis or pulmonary embolism (6–8). Traditional treatment of VTE is used for Covid-19 patients with coagulopathy, and this includes heparin, low-molecular-weight heparin and direct oral anticoagulants, such as apixaban. Anti-inflammatory medications are also being given to protect endothelial cells (9).
Conclusions: This case of cavernous sinus thrombosis in a patient with Covid-19 highlights the importance of considering hypercoagulability and superinfection as adverse effects of the infection. The pathophysiology of this process is not fully understood; however, there are treatment options available.