MR imaging of cavernous sinus invasion by mucormycosis: a case study

doi:10.1016/S0303-8467(01)00122-6

Clinical Neurology and Neurosurgery

Volume 103, Issue 2, July 2001, Pages 101-104

https://doi.org/10.1016/S0303-8467(01)00122-6 Get rights and content

Abstract

Cavernous sinus thrombosis is a serious condition, which, if not recognized early, can lead to a fulminant course. Knowledge of risk factors along with early recognition of signs and symptoms may alter the course of this condition. We present a case of a patient with cavernous sinus thrombosis with characteristic findings on MRI. Biopsy of the sinuses revealed mucromycosis as the offending agent.

Introduction

Thrombosis of the cavernous sinus is potentially a lethal condition usually due to bacterial or fungal invasion complicating sinusitis, in patients with poorly controlled diabetes or immuno-suppression [1], [2], [3], [5], [9]. Vascular, traumatic, and neoplastic etiologies of cavernous sinus thrombosis are also reported [4], [10]. Early recognition of clinical signs and symptoms of this life-threatening condition is essential [8], [11], [12].

We describe the case of a 53 year old patient with underlying SLE who suffered complications of rhino-cerebral mucormycosis while she was hospitalized. The neurologic presentation and examination suggested cavernous sinus thrombosis, which was elegantly depicted by MR imaging and confirmed by biopsy of the sinuses.

Section snippets

Case study

The patient is a 53 year old female who was in excellent health until 4 months prior to presentation. She described a progressive decline in her health characterized by fatigue, weight loss, arthralgias, and dyspnea on exertion. These symptoms were accompanied by intermittent fever, chills, nausea, and vomiting.

She presented to the emergency room where she was found to be in renal failure with a BUN of 141 and creatinine of 6.2. The signs and symptoms at presentation were thought to be due to

Discussion

Cavernous sinus thrombosis is a life-threatening illness, which, if recognized early, may result in reduced morbidity and mortality [5], [9]. As is the case in this patient, benign-appearing facial swelling may progress quickly to chemosis, proptosis and opthalmoplegia.

The venous drainage and arterial blood supply to the orbits and sinuses lends itself to bacterial and fungal pathogen spread to the cavernous sinus in a retrograde fashion via the superior and inferior ophthalmic veins [5].

Acknowledgements

Dr Al Rampy provided help with histopathology.

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Étude rétrospective portant sur 29 cas de sinusites aiguës avec extension oculo-orbitaire colligés sur une période de 12 ans (2000 à 2012).
Il s’agit de 23 hommes et 6 femmes. L’âge moyen était de 15,75 ans. Le délai moyen de consultation était de 7,68 jours. L’atteinte était ethmoïdo-maxillaire dans 20 cas, ethmoïdale dans 6 cas, frontale dans 3 cas. L’atteinte orbitaire a été classée selon la classification de Chandler en stade I (3 cas), stade II (3 cas), stade III (15 cas), stade IV (8 cas). L’antibiothérapie a été prescrite dans tous les cas. La chirurgie a été pratiquée dans 22 cas. Les prélèvements bactériologiques ont conclu à un streptocoque (2 cas), aspergillus fumigatus (1 cas) et étaient négatifs dans 8 cas. L’évolution était favorable dans 27 cas. Dans deux cas, l’évolution était défavorable devant l’association de complication endocrânienne.
L’extension oculo-orbitaire des sinusites aiguës est une urgence diagnostique et thérapeutique. Le scanner des sinus de la face est essentiel pour confirmer l’extension orbitaire et l’infection sinusienne causale. L’antibiothérapie intraveineuse reste de mise. La place de la corticothérapie et l’héparinothérapie reste discutée. La chirurgie est indiquée en cas de collection ou en cas de mise en jeu de pronostic visuel. La chirurgie endonasale par voie endoscopique semble avoir un double intérêt diagnostique et thérapeutique.
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Oculoorbital extension of acute sinusitis is a diagnostic and therapeutic emergency. Paranasal sinus CT is essential to confirm orbital extension and identify the causative sinus. Intravenous antibiotic therapy is the main treatment. The roles of corticosteroid and heparin therapy remain controversial. Surgery is indicated in the case of abscess or high visual risk. Endoscopic endonasal surgery appears to have a double role, in diagnosis and treatment.
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In an accompanying retrospective study, mortality in patients with an accompanying intracranial hemorrhage treated with heparin was 15% as compared with 69% in similar patients not receiving anticoagulation (Einhaupl et al., 1991). Current recommendations are for use of unfractionated heparin in venous sinus thrombosis, including those cases in which hemorrhage is present (Einhaupl et al., 2006; Shafqat et al., 2006; Albers et al., 2008; Ferro and Canhao, 2008; Masuhr and Einhaupl, 2008). Treatment with low-molecular-weight heparin has also been used; however, a placebo-controlled trial, using the low-molecular-weight compound nadroparin, although yielding slightly better results in the treatment group, did not reach statistical significance (Stam et al., 2002).
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MR imaging of cavernous sinus invasion by mucormycosis: a case study

Abstract

Introduction

Section snippets

Case study

Discussion

Acknowledgements

Radiol. Clin. North Am.

Mayo Clin Proc

Invasive aspergillosis presenting as a cavernous sinus mass in immuno-competent individuals; report of 3 cases

Neuroradiology

Overwhelming septic cavernous sinus thrombosis in a woman after combination of high-dose steroid and intravenous cyclophosphamide therapy for lupus nephritis

Lupus

Orbital apex syndrome and cavernous sinus thrombosis due to infection with staphylococcus aureus and pseudomonas aeruginosa

Clin. Infect. Dis.

Cavernous sinus invasion by pituitary adenoma

MR Imaging