| Identifier |
walsh_2019_s1_c1 |
| Title |
A Zebra Among Zebras |
| Creator |
Peter Mortensen; Gabrielle Bonhomme |
| Affiliation |
(PM) (GB) UPMC Eye Center, Pittsburgh, Pennsylvania |
| Subject |
Cavernous Sinus Syndrome, Thrombosis, Jugular Veins, Proptosis, Optic Neuropathy |
| History |
61-year-old man with Type 2 diabetes and hypertension presented to outside hospital ED with fever, headache, and neck pain. Onset of neck pain was one week prior, with worsening of symptoms following chiropractic manipulation. Patient was evaluated at outpatient clinic one day prior and given Medrol Dosepak for degenerative disc disease. In the ED, he had fever 102.5F, headache, neck pain, and right-sided blurry vision followed by rapid development of chemosis, proptosis, ophthalmoplegia, and nonreactive right pupil. Labs revealed leukocytosis and elevated lactate. Chest X-Ray revealed pulmonary nodules and C-spine CT revealed retropharyngeal abscess. CT head was unremarkable. Patient was started on broad spectrum antibiotics and was transported. After transfer to the medical ICU, ophthalmology was stat paged for loss of vision in his right eye during transport. Ophthalmology arrived minutes later and was the first team at bedside. Our examination was notable for visual acuity hand motions 1' (right) and 20/200 (left), fixed and dilated right pupil with afferent pupillary defect, intraocular pressure 60 (right) and 26 (left), and omnidirectional ophthalmoplegia bilaterally. Anterior segment was notable for right-sided chemosis and proptosis with fixed, dilated pupil. Fundus examination was unremarkable. Right lateral canthotomy and cantholysis performed, with pressure decreasing to 30. ENT performed bedside laryngoscopy, with no concern for fungal etiology. Bedside ultrasound demonstrated thrombus in the right internal jugular vein. We immediately discussed the case with neurosurgery, oculoplastics, medical ICU team, and ENT, with urgent angiogram strongly recommended. Shortly thereafter, patient reported loss of vision in the left eye, with bilateral fixed and dilated pupils. Due to acute worsening of his condition, angiogram was not obtained. CT orbit demonstrated bilateral cavernous sinus thrombosis, bilateral internal jugular thrombi, and retropharyngeal abscess. Patient was continued on broad spectrum antibiotics and intubated. He became unresponsive and succumbed to infection the following day. |
| Disease/Diagnosis |
Given the patient's retropharyngeal abscess, bilateral pulmonary nodules, and bilateral internal jugular vein thrombi, the patient was diagnosed with Lemierre's syndrome. He developed bilateral cavernous sinus thrombosis, which rarely occurs from Lemierre's. Karkos et al., 2009, noted that cavernous sinus thrombosis only occurred in roughly 5% of cases. Interestingly, his blood cultures returned positive for Staph aureus rather than Fusobacterium, which causes roughly 90% of Lemierre's cases. Most patients with Lemierre's syndrome present in their second or third decade of life (median age 22), though there have been cases documented in patients ranging from 2 months old to 78 years old. Lemierre's syndrome has a 5% mortality rate, and the patient's rapid decline may be attributed to his atypical presentation, especially given the development of bilateral cavernous sinus thrombosis. The administration of steroids one day prior to his hospitalization may have contributed to his decline. |
| Date |
2019-03 |
| References |
1. Karkos PD, Asrani S, Karkos CD, Leong SC, Theocari EG, et al: Lemierre's syndrome: a systematic review. Laryngoscope 2009; 119: 1552-9. |
| Language |
eng |
| Format |
video/mp4 |
| Type |
Image/MovingImage |
| Source |
2019 North American Neuro-Ophthalmology Society Annual Meeting |
| Relation is Part of |
NANOS Annual Meeting Frank B. Walsh Sessions; 2019 |
| Collection |
Neuro-Ophthalmology Virtual Education Library: Walsh Session Annual Meeting Archives: https://novel.utah.edu/Walsh/ |
| Publisher |
North American Neuro-Ophthalmology Society |
| Holding Institution |
Spencer S. Eccles Health Sciences Library, University of Utah |
| Rights Management |
Copyright 2019. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright |
| ARK |
ark:/87278/s6v16p05 |
| Setname |
ehsl_novel_fbw |
| ID |
1431946 |
| Reference URL |
https://collections.lib.utah.edu/ark:/87278/s6v16p05 |
