A 45-year-old woman, with a medical history of IV drug use and chronic hepatitis C virus infection presented to our institution with a complaint of right eye pain and inability to see. She stated that she had popped a pimple on her right cheek, 4 days prior, with progression of swelling, tenderness, and finally loss of vision. On physical exam, the patient was afebrile but confused. Her right eye was swollen with purulent discharge, and she had nerve palsy of CN III-VII on the right side. A 4-mm indurated eschar was noted on the right cheek. No obvious dental caries were appreciated. With the exception of track marks and coarse breath sounds, the remainder of the exam was normal. Laboratory studies showed leukocytosis with neutrophilia, and an elevated ESR, CRP, and lactate. CT of the head without contrast showed a prominent cavernous sinus. MRI further indicated ventriculitis, as well as concern for cavernous sinus thrombus. Blood cultures grew out methicillin-resistant Staphylococcus aureus. During her hospital stay, she underwent canthotomy but deteriorated with subsequent development of septic shock and multi-organ failure. Five days after presentation, the patient passed away.
Cerebral vein thrombosis (CVT) is an uncommon entity, with less than 1.5 incidences per 100,000. CVT has a higher prevalence in neonates and children, though when found in adults, favors younger adults. The exact pathogenesis of CVT remains unclear, though risk factors include prothrombotic conditions, oral contraceptive pill use, pregnancy, malignancy, infection, and head injury. Infection from popped comedones in the danger triangle of the face can travel through the facial vein and seed the cavernous sinus. Eventually the cavernous sinus drains into the internal jugular vein, allowing for spread of infection to the venous supply of the brain. The most common cause of septic CVT is S. aureus. Thrombosis results in headache with increased intracranial pressure, focal deficits, and possible loss of vision. This case appears to be a combination of infection causing thrombophlebitis, with severe sepsis causing multi-organ failure.
Despite the low incidence of cerebral venous thrombosis, clinicians should consider thrombosis in septic patients who present with a seemingly harmless pimple flaw. Furthermore, a heightened sense of concern should exist if altered mental status, focal neurologic deficits, and other evidence of increased intracranial pressure are present. This case illustrates the severity of cerebral venous infections and secondary thrombosis. This case illustrates the severity of cerebral venous infections and secondary thrombosis.