Case Presentation: A 9-year-old male with 5-day history of headache, fever, somnolence, red eyes and fatigue presented to the ED due to concern for Kawasaki disease. In the ED, frontal headache, fever, photophobia, and neck pain were noted raising concern for meningitis. Screening MRI brain did not demonstrate acute intracranial abnormality, but did show sinus disease. Lumbar puncture revealed normal spinal fluid values. Ampicillin/sulbactam was started for treatment of sinusitis. Following admission, the patient’s headache and neck pain persisted and his somnolence worsened. A complete MRI of the brain and C-spine with and without contrast was performed revealing left sphenoid sinus disease with erosion into the skull base, dural thickening and moderate narrowing of the right internal carotid artery. Sphenoid sinus incision and drainage with resection was done. Blood cultures from the PCP’s office grew Streptococcus anginosus. Antibiotic coverage was changed to vancomycin, metronidazole, and ceftriaxone. To further assess dural changes, a repeat MRI and MRV was performed, confirming the diagnosis of cavernous sinus thrombosis (CST). Anticoagulation with enoxaparin was initiated. Surgical cultures grew Streptococcus intermedius, and antibiotic coverage was narrowed to ceftriaxone and metronidazole.
The patient gradually improved with resolution of headache and normalization of mental status. He was discharged on enoxaparin, IV ceftriaxone and oral metronidazole. Antibiotics continued for a total of 6 weeks. Repeat MRI showed patent flow in the right cavernous sinus and resolution of right ICA narrowing. Anticoagulation with enoxaparin was stopped at 3 months. He continues to do well, without sequelae from his cavernous sinus thrombosis.

Discussion: The incidence of CST in childhood is rare, between 0.4 and 0.7 per 100,000 children per year. The diagnosis should be considered when ocular signs predominate including orbital pain, chemosis, proptosis, conjunctival injection and oculomotor palsies. Headache is often associated, and patients affected may complain about changes in the way their face feels or moves. A high index of suspicion and appropriate imaging are key to making the diagnosis. CT can miss CST in up to 40% of patients, so MRI is the imaging modality of choice with MR venogram being the most sensitive. Treatment of CST includes general supportive care or symptomatic measures including correction of dehydration and hypovolemia, antibiotics for cases where infection is identified, anticonvulsants to control seizures, and surgical measures aimed at decreasing intracranial pressure. Though practice varies, 3-6 months of anticoagulation is usual with duration influenced by evidence of recanalization on follow-up imaging.

Conclusions: A high index of suspicion, prompt and appropriate imaging, and early initiation of treatment is critical for identification and favorable outcomes for patients with CST.