Presentation
Fever, sinusitis, presyncopal episode, and vomiting/diarrhea.
Patient Data
Contrast-enhanced MRI confirms the presence of thrombus and asymmetric enlargement of the right superior ophthalmic vein. No definite filling defect demonstrated in the right cavernous sinus with symmetric bilateral opacification.
The left superior ophthalmic vein is patent. No inflammation of the orbits. The dural venous sinuses are patent.
Opacification of the right sphenoid sinus. There is no appreciable intracranial extension or surrounding inflammatory change.
There is also mild mucosal thickening of the maxillary, left sphenoid sinuses.
There is no acute intracranial hemorrhage, acute large vessel infarct or focal intracranial mass lesion.
Summary:
1. Thrombus in the right superior orbital vein. No definite extension into the cavernous sinuses on MRI.
2. Appearance of the material in the right sphenoid sinus is atypical for mucus or proteinaceous fluid, findings may be related to chronic sinusitis, but fungal sinusitis should be considered in the appropriate clinical setting.
The green arrow points to the right superior ophthalmic vein which is distended with intraluminal non-enhancing thrombus.
Case Discussion
This lady presented feeling generally unwell. Her symptoms included right-sided sinusitis - headaches/pressure which she stated felt like previous sinus headaches. She also reported right-sided nasal blockage and purulent nasal discharge (brown/green/blood-stained). Neurological examination was grossly normal and she reported no visual disturbance.
She developed sepsis and her admission was complicated by NSTEMI and APO. Treatment with antibiotics, dual antiplatelet and ACE inhibitors, beta-blockers and diuretics.
The diagnosis was right sphenoid sinusitis (possibly fungal and bacterial) with S. aureus bacteremia (likely source for superior ophthalmic vein thrombus).
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