Case Presentation: A 75-year-old man with a past history of diverticulitis was admitted five days prior for a small bowel obstruction (SBO). At the time of admission, he had a sore throat and nasal congestion, and a respiratory pathogen panel was positive for RSV. On admission, a nasogastric tube (NG) was placed for decompression with difficulty placing due to a deviated septum. The SBO was resolving and the NG tube was clamped. He had headaches during admission, originally responding well to acetaminophen, which worsened to a severe frontal headache feeling like something was “drilling into him” on hospital day four despite treatment with multiple analgesics. CT of the head showed signs of complete opacification of the R sphenoid sinus. He was started on treatment for secondary bacterial sinusitis but within four hours, developed a fever to 39.2C with leukocytosis to 27×109/L (48%N, 49%L) and was confused and disoriented on exam with pinpoint pupils but preserved extraocular movements and with neck stiffness but negative Brudzinski’s and Kernig’s sign. He was started on meningitis treatment with acyclovir, vancomycin, meropenem due to penicillin allergy and planned to receive a lumbar puncture. It is found he had likely self-administered 650mg of aspirin for headache delaying the lumbar puncture. Blood cultures return positive for gram positive bacteria in clusters. A MRV was performed due to concern for cavernous sinus thrombosis which showed bilateral acute maxillary and sphenoid sinusitis and thrombosis of bilateral cavernous sinuses and bilateral superior ophthalmic veins. He started on a heparin drip. The next morning, the patient had right eye proptosis and reduced abduction of the eye. He underwent urgent endoscopic sinus surgery with otolaryngology. Blood cultures and sinus cultures both grew methicillin-resistant S. aureus (MRSA). He completed six weeks of antibiotics and ultimately had a good outcome with resolution of visual and nasal symptoms.
Discussion: S. aureus is an uncommon cause of meningitis (1-9% of total cases). Most cases of MRSA meningitis (>90%) were acquired in the hospital after surgery. S. aureus meningitis is associated with suppurative complications in 14% of cases and has a high mortality rate (23% in one case study)1. However, S. aureus is the most common pathogen causing septic cavernous sinus thrombosis (SCST)2. Ethmoid and/or sphenoid sinusitis is the source of infection in over half of cases. The average latent period between predisposing infection and SCST is 5-6 days. Symptoms include fever 90%, headache 60-90% (often retro orbital), and ophthalmoplegia, most often lateral rectus palsy, in 50% − 80% of cases3. Mydriasis or miosis may also be present. 40% of patients have concurrent meningitis. SCST has a mortality- 20-30% with 50% with neurological defects2. This patient’s preexisting viral infection, nasal septal deviation, and presence of an NG tube predisposed to an uncommon infection.
Conclusions: It is important for a hospital medicine provider to be able to triage headache syndromes and identify red flag symptoms. In this case, prompt identification of red flag symptoms led to the concern for meningitis. The presence of S. aureus bacteremia led to concern for cavernous sinus thrombosis before gaze restriction was present. Early treatment and sinus surgery led to a good outcome of a life-threatening disease.
