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Título

Septic Thrombophlebitis of the Cavernous Sinus After a Hymenoptera Accident: a Case Report

RESUMO

Introduction: Cavernous sinus thrombosis can result from any facial infection of the region drained by this sinus. Case description: A 23 year old male patient, previously healthy, was admitted to the emergency department reporting an insect bite on the nasal dorsum 05 days ago. Since then he had pain, edema and hyperemia in bilateral peri-orbital region, worse to the left, followed by decreased general condition, myalgia, headache, fever, neck stiffness and mental confusion. Laboratory tests showed signs of bacterial meningitis, and treatment with Ceftriaxone was initiated with improvement of the meningeal picture. Computed tomography (CT) of the skull showed signs of thrombosis of the transverse sinus, sigmoid and left internal jugular vein, confirmed by magnetic resonance imaging of the brain. Anticoagulation therapy was started with warfarin. Arteriography showed a carotid-cavernous fistula, but it was decided to maintain anticoagulation due to extensive central venous thrombosis. Besides the neurological picture, cavitary lesions were found on chest CT and bronchoscopy was requested for investigation, however the result of the biopsy showed only signs of inflammation with inconclusive result. After suspension of anticoagulation 24 hours before the bronchoscopy, the patient evolved with motor aphasia and cranial CT showed foci of ischemia. After returning to anticoagulation, there was improvement of neurological deficits. After stabilization and absence of active infectious signs, the patient was referred to vascular neurosurgery for fistula repair. However, a new pre-surgical arteriography showed total and spontaneous correction of the fistula through thrombosis of its path and also revascularization of central venous thrombosis. Conclusion: Septic cavernous sinus thrombosis is an uncommon and serious complication of facial infections, and occurs when the infected areas are close to the nose because this region is drained by the ophthalmic veins. About 20 to 30% of cases have fatal outcomes. The importance of this report lies in the rarity of the case associated with the singularity of the event of spontaneous fistula correction.