A 23-year-old man comes to the physician complaining of worsening headache over the past week. He is "under a lot of stress at school" and having trouble sleeping because the headache is constant. Two weeks ago, he had an insect bite on his right cheek and now both of his eyes are swollen. He also has lost his appetite and vomited twice today. His temperature is 38.3° C (101° F), blood pressure is 130/90 mm Hg, pulse is 104/min, and respirations are 20/min. Examination shows erythema and swelling of the right cheek and bilateral eyelid edema, right greater than left. Bilateral extraocular movements are restricted. The bilateral forehead and mid-face are extremely tender to light palpation. Which of the following is the most likely diagnosis?

Question

A 23-year-old man comes to the physician complaining of worsening headache over the past week.  He is "under a lot of stress at school" and having trouble sleeping because the headache is constant.  Two weeks ago, he had an insect bite on his right cheek and now both of his eyes are swollen.  He also has lost his appetite and vomited twice today.  His temperature is 38.3° C (101° F), blood pressure is 130/90 mm Hg, pulse is 104/min, and respirations are 20/min.  Examination shows erythema and swelling of the right cheek and bilateral eyelid edema, right greater than left.  Bilateral extraocular movements are restricted.  The bilateral forehead and mid-face are extremely tender to light palpation.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

The most likely diagnosis in this patient is infectious cavernous sinus thrombosis (CST). Because the facial/ophthalmic venous system is valveless, uncontrolled infection of the skin, sinuses, and orbit can spread to the cavernous sinus. Inflammation of the cavernous sinus subsequently results in life-threatening CST and intracranial hypertension. Headache is the most common symptom and can become intolerable. A low-grade fever and periorbital edema usually occur several days later secondary to impaired venous flow in the orbital veins. Vomiting is also a result of intracranial hypertension, and fundoscopy may reveal papilledema. facial/ophthalmic venous system 11ec25c8_d59a_a026_bc81_a3f33f16e72c_MD0003_00 Cranial nerves III, IV, V, and VI pass through the cavernous sinus, which has anastomoses crossing midline. As a result, unilateral symptoms (eg, headache, binocular palsies, periorbital edema, hypoesthesia, or hyperesthesia in V1/V2 distribution) can rapidly become bilateral. Magnetic resonance imaging with magnetic resonance venography is the imaging modality of choice for diagnosis of CST. Treatment includes broad-spectrum intravenous antibiotics and prevention or reversal of cerebral herniation. (Choice A) Acute angle-closure glaucoma typically occurs in elderly patients and presents with eye pain, visual loss, and headache. The presence of cranial nerve deficits and bilateral distribution makes this diagnosis unlikely. (Choice B) Brain abscess should be considered in any patient with fever, headache, and focal findings on neurologic examination. Increased intracranial pressure from brain abscess would cause brain herniation but not bilateral periorbital edema. (Choice C) Cluster headache is characterized by brief, repetitive orbital headaches that are accompanied by autonomic symptoms. Periorbital edema and bilateral cranial nerve deficits would not be seen. (Choice E) Migraine is characterized by severe, episodic headaches associated with nausea and photophobia. This patient's headache was constant over several days and accompanied by binocular palsies, making migraine unlikely. (Choice F) Periorbital (preseptal) cellulitis is a mild infection of the eyelid anterior to the orbital septum and can present with fever and eyelid erythema/edema. However, this patient has inflammation extending beyond the orbital septum. Ophthalmoplegia is a sign of orbital muscle and/or nerve damage and the presence of headache and bilateral face and eye symptoms reflect involvement of the cavernous sinus. Educational objective: Because the facial/ophthalmic venous system is valveless, uncontrolled infection of the skin can result in cavernous sinus thrombosis. Red-flag symptoms include severe headache; bilateral periorbital edema; and cranial nerve III, IV, V, and VI deficits. References: Challenging presentations of cavernous sinus thrombophlebitis. (http://www.ncbi.nlm.nih.gov/pubmed/15858188) Ocular manifestations of cavernous sinus thrombosis. (http://www.ncbi.nlm.nih.gov/pubmed/22802153)

A 23-Year-Old Man Comes to the Physician Complaining of Worsening