a case of eye pain and confusion
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A Case of Eye Pain and ConfusionA Case of Eye Pain and Confusion
Daniel G. Murphy, MD, FACEP
Vice Chair & Medical Director
Maimonides Medical Center
Brooklyn, New York
Daniel Murphy, MD
First ED Visit: Late Friday NightFirst ED Visit: Late Friday Night
• 24 yo female with headache for 2 weeks, worse over the last 2 days
• 104/76, 80, 18, 98.1F• Right frontal forehead, sharp, non-radiating,
constant but waxing/waning, worse when she moved.
• (+) nausea• (-) fever, photophobia, neck pain or visual
changes
Daniel Murphy, MD
Past Medical/Social HistoryPast Medical/Social History
• No recent trauma• Smoker 1 PPD• Social drinker• No hx of headaches, except for last 2 weeks• No allergies• No meds except ibuprofen and acetaminophen
recently – not helpful• Worked as a part-time sales clerk
Daniel Murphy, MD
Exam: First VisitExam: First Visit
• Alert, oriented, looked well except for discomfort of headache
• Face normal, Perrl, EOMI, fundi normal, TMs normal, mastoids non-tender, neck supple, motor neuro exam normal, normal gait, mental status normal
Daniel Murphy, MD
ED Therapy and Work UpED Therapy and Work Up
• Prochlorperazine 10 mg, by vein Acetaminophen 325/Oxycodone 5, orally
• CBC, Chem 7, UCG, CT Head without contrast
Daniel Murphy, MD
ED Diagnostic Results: Visit 1ED Diagnostic Results: Visit 1
• WBC count 12.4K
• CT head reviewed by ED attending and radiology resident as negative
Daniel Murphy, MD
ED Disposition: Visit 1ED Disposition: Visit 1
• Patient’s pain responded to medications
• Patient discharged with prescription for acetaminophen/butalbital/caffeine = Fioricet
Daniel Murphy, MD
Radiology Over-Read: Monday AMRadiology Over-Read: Monday AM(2.5 days since 1(2.5 days since 1stst ED visit) ED visit)
• Opacification of the right ethmoid and right sphenoid sinuses with expansion of the sphenoid septations toward the left.
• No intracranial disease
Daniel Murphy, MD
ED Discrepancy ProcedureED Discrepancy Procedure
• Patient was contacted by phone and informed of sinus problem on CT
• Patient went to her PMD that afternoon
• PMD discharged her with prescription for levofloxacin
Daniel Murphy, MD
22ndnd ED Visit: Tuesday Morning ED Visit: Tuesday Morning(3.5 days after 1(3.5 days after 1stst ED visit) ED visit)
• New onset swelling and severe pain around left eye
• Continued, worsening right-sided headache
• Slept poorly, confused, hallucinating?
• 100/80, 96, 18, 101.9F
Daniel Murphy, MD
Morning Exam: 2Morning Exam: 2ndnd Visit Visit
• Left peri-orbital edema, erythema, proptosis, chemosis, severe pain with EOMs. Left pupil reacted to light.
• Ambulated in with normal gait. No obvious motor deficits.
• Awake. Followed simple commands, but mildly confused, answering slowly or incorrectly, with difficulty concentrating.
• (+) Nuchal rigidity
Daniel Murphy, MD
ED Therapy & Work UpED Therapy & Work Up
• 2 grams ceftriaxone by vein after cultures• Repeat CT of brain and sinuses with contrast• LP• ID and ENT consults; vancomycin and
metronidazole given by vein • Admitted to MICU
Daniel Murphy, MD
Daniel Murphy, MD
Daniel Murphy, MD
Afternoon Exam: 2Afternoon Exam: 2ndnd Visit Visit
• Deteriorating mental status.
• Mild left sided weakness left upper and left lower extremities.
Daniel Murphy, MD
ED Admitting DiagnosesED Admitting Diagnoses
• Orbital Cellulitis
• Meningitis
• Rule out Cavernous Sinus Thrombosis
Daniel Murphy, MD
Septic Dural Sinus ThrombosisSeptic Dural Sinus ThrombosisSuppurative Intracranial ThrombophlebitisSuppurative Intracranial Thrombophlebitis
• Infected venous thrombosis of cortical veins or sinuses
• From meningitis, subdural empyema, epidural abscess, infection in the skin of the face, paranasal sinuses, middle ear, mastoid, maxillary teeth or neck.
• Iatrogenic cases have been associated with rhinoplasty, hip surgery and oral/dental surgery.
Daniel Murphy, MD
Non-Septic Dural Sinus ThrombosisNon-Septic Dural Sinus Thrombosis
• Dehydration from vomiting
• Hypercoagulable states
• Immunologic abnormalities, including the presence of circulating antiphospholipid antibodies
Daniel Murphy, MD
Septic Dural Sinus ThrombosisSeptic Dural Sinus Thrombosis
• Rare; 155 reported cases since 1940• Cavernous Sinus Thrombosis (CST) is
the predominant subset (62%?)• Fulminant, aggressive disease: mortality
CST =30%, superior sagittal sinus thrombosis =78%
• Morbidity CST: 50% cranial nerve deficit; 17% visually impaired
Daniel Murphy, MD
Infected Thrombus PathogensInfected Thrombus Pathogens
• CST: Staphylococcus aureus, other gram-positive organisms, and anaerobes.
• Lateral Sinus (otitis media and/or mastoid infection) Proteus species, Escherichia coli, S. aureus, and anaerobes.
• Superior Sagittal Sinus (meningitis or air sinus infection) - Streptococcus pneumoniae, S. aureus, other streptococci, and Klebsiella species.
Daniel Murphy, MD
ED Presentation: ED Presentation: Superior Sagittal Sinus ThrombosisSuperior Sagittal Sinus Thrombosis
• Headache, nausea and vomiting, confusion, and focal or generalized seizures.
• Rapid development of stupor and coma.
• Weakness of the lower extremities with bilateral Babinski signs or hemiparesis is often present.
Daniel Murphy, MD
• Headache and earache.
• Gradinego's syndrome: otitis media, sixth nerve palsy, and retro-orbital or facial pain.
• Sigmoid sinus and internal jugular vein thrombosis may present with neck pain.
ED Presentation: ED Presentation: Transverse Transverse Sinus ThrombosisSinus Thrombosis
Daniel Murphy, MD
• Sinusitis, midface infection for 5-10 days.• Fever, headache, malaise, retro-orbital pain and
diplopia, which generally precede…..• Ptosis, proptosis, chemosis, eyelid edema, peri-orbital
edema and extraocular dysmotility due to deficits of cranial nerves III, IV, and VI.
• Hypo- or hyperesthesia of the ophthalmic and maxillary divisions of V, decreased corneal reflex. dilated, tortuous retinal veins and papilledema.
• Meningeal signs: nuchal rigidity, Kernig and Brudzinski signs.
ED Presentation: ED Presentation: Cavernous Cavernous Sinus ThrombosisSinus Thrombosis
Daniel Murphy, MD
Diagnostic StudiesDiagnostic Studies
• CBC, diff, cultures
• Sinus Films, CT, MR, MR Venography, Venous phase cerebral angiogram
• LP
Daniel Murphy, MD
Daniel Murphy, MD
Daniel Murphy, MD
Daniel Murphy, MD
Daniel Murphy, MD
Daniel Murphy, MD
Daniel Murphy, MD
Daniel Murphy, MD
ED ManagementED Management
• Antibiotics: S aureus is the usual cause, broad-spectrum coverage for gram-positive, gram-negative, and anaerobic organisms also, pending cultures.
• Drain primary source of infection, if feasible (eg, sphenoid sinusitis, facial abscess).
• Anticoagulation in carefully selected cases of septic cavernous-sinus thrombosis, not other forms of septic dural-sinus thrombosis.
• Urokinase or rtPA?• Corticosteroids?
Daniel Murphy, MD
ConsultsConsults
• ENT
• Neurology
• ID
• Intensive Care
Daniel Murphy, MD
Outcome of CaseOutcome of Case
• Day 1: Seizure, worsening deficit, intubated
• Day 2: Heparinized, transient neuro improvement then relapse.
• Day 5: Sinuses drained
• Day 6: Brain dead
• Day 19: Demise
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