Figura 1. Resonancia magnética craneal T2W (a) y angiorresonancia (b). Arteria carótida interna izquierda con engrosamiento concéntrico de su luz en su porción intracraneal (flechas) en comparación con su contralateral sana.
Figura 2. Tomografía por emisión de positrones-tomografía axial computarizada craneal: se observa un foco de hipercaptación en la región pretarsiana izquierda que respeta el lado derecho.
Figura 3. Resonancia magnética craneal T2W que revela cambios inflamatorios en la región temporal izquierda compatibles con cerebritis y formación de abscesos que provocan desplazamiento de la línea media de 7 mm y herniación uncal.
Cavernous sinus syndrome secondary to thrombophlebitis due to Streptococcus intermedius complicated with vasculitis of the internal carotid artery and brain abscesses
Introduction. Thrombophlebitis of the cavernous sinus is a severe infectious disease with high mortality and morbidity. It is usually diagnosed at a late stage and requires a number of visits to the emergency department in most cases, and the prognosis is highly dependent on prompt treatment. Despite its severity, evidence regarding treatment with corticosteroids and anticoagulation therapy is scarce and controversial. One of its complications is arteritis, which can be mistaken for medium to large vessel vasculitis, as in this case.
Case report. A 26-year-old female, who visited due to headache and left palpebral oedema. Imaging tests revealed thrombosis in the left cavernous sinus and significant narrowing of the internal carotid artery. The clinical picture was interpreted as secondary to an inflammatory vascular process and treatment with corticosteroids was initiated, with a good response. However, soon afterwards, fever and contralateral palpebral oedema developed. In the blood cultures a growth of Streptococcus intermedius was obtained and thrombophlebitis of the cavernous sinus was diagnosed. Despite initiating antibiotic and anticoagulation therapy, the patient suffered a right hemiplegia secondary to the formation of frontotemporal abscesses. Surgical drainage was performed and the patient progressed well. In the absence of other infectious foci, and due to the oral origin of the germ, a prophylactic multiple exodontia was performed.
Conclusion. Thrombophlebitis should be considered as a diagnostic option both in headaches with ocular symptoms and in medium to large vessel arteritis so that they can be treated in a timely manner.
Key words. Arteritis of the internal carotid artery. Brain abscesses. Holocranial headache. Palpebral oedema. Streptococcus intermedius. Thrombophlebitis of the cavernous sinus.