Abstract Details

Title Unilateral Periorbital and Facial Swelling with Multiple Unilateral Cranial Nerve Deficits in an Uncontrolled Diabetic

Topic Infectious Disease

Presentation(s) P5 - Poster Session 5 (5:30 PM-6:30 PM)

Poster/Presentation
Number 4-024

Objective To discuss cavernous sinus thrombosis as a complication of invasive fungal sinusitis.

Background This patient is a 45-year-old female with poorly controlled type 2 diabetes mellitus. Neurology was consulted to evaluate unilateral findings of periorbital and facial edema with cranial neuropathies. She presented with four days of progressive left facial numbness, edema, and purulent nasal drainage. On neurological exam, she had left periorbital edema with unreactive pupil, no light perception, grade II papilledema, and ophthalmoplegia of her left eye. Muscles of facial expression remained intact. An eschar was found on her left inferior turbinate. Her hemoglobin A1c was found to be 13% and her WBC count was 19.4 k/uL. These findings prompted concern for complicated invasive fungal sinusitis. Initial CT venography was inconclusive, but MRI revealed cavernous sinus thrombosis. Nasal cultures showed Rhizopus species. Treatment with antifungal drugs and heparin were insufficient, so she underwent orbital exoneration, durotomy, and hemimaxillectomy.

Design/Methods NA

Results NA

Conclusions Invasive fungal sinusitis progresses rapidly in a patient with uncontrolled diabetes. Neurologists must keep a high clinical suspicion in at risk patients. Clinical features include fever, facial pain and swelling, nasal congestion, and epistaxis. Cranial nerve testing is vital, as specific deficits increase suspicion for cavernous sinus thrombosis. Findings include facial numbness from involvement of the first two branches of the trigeminal nerve and ophthalmoplegia from involvement of the oculomotor, trochlear, and abducens nerves. In this clinical context, CT or MRI is indicated to assess for cavernous sinus thrombosis. Nasal mucosa should be evaluated for necrosis, as definitive diagnosis of invasive fungal sinusitis must be made by histopathology. Empiric treatment with amphotericin B and debridement of infected tissues is indicated to prevent further invasion. Even in septic cavernous sinus thrombosis, such as with this patient, the addition of anticoagulation may be indicated to prevent contralateral cavernous sinus thrombosis.

Authors/Disclosures
Frank Dicken PRESENTER	No disclosure on file
Tarek E. Ali, MBBS (University of Kentucky College of Medicine)	Dr. Ali has nothing to disclose.
Fred Odago, MD (St. Joseph Medical Group Neurology)	No disclosure on file
Ima M. Ebong, MD, FAAN (University of Kentucky)	The institution of Dr. Ebong has received personal compensation in the range of $500-$4,999 for serving as a Consultant for UCB. The institution of Dr. Ebong has received research support from Ad Scientiam.

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