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A Case of Eye Pain and Confusion

A Case of Eye Pain and Confusion. Daniel G. Murphy, MD, FACEP Vice Chair & Medical Director Maimonides Medical Center Brooklyn, New York. First ED Visit: Late Friday Night. 24 yo female with headache for 2 weeks, worse over the last 2 days 104/76, 80, 18, 98.1F

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A Case of Eye Pain and Confusion

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  1. A Case of Eye Pain and Confusion Daniel G. Murphy, MD, FACEP Vice Chair & Medical Director Maimonides Medical Center Brooklyn, New York

  2. First ED Visit: Late Friday Night • 24 yo female with headache for 2 weeks, worse over the last 2 days • 104/76, 80, 18, 98.1F • Right frontal forehead, sharp, non-radiating, constant but waxing/waning, worse when she moved. • (+) nausea • (-) fever, photophobia, neck pain or visual changes

  3. Past Medical/Social History • No recent trauma • Smoker 1 PPD • Social drinker • No hx of headaches, except for last 2 weeks • No allergies • No meds except ibuprofen and acetaminophen recently – not helpful • Worked as a part-time sales clerk

  4. Exam: First Visit • Alert, oriented, looked well except for discomfort of headache • Face normal, Perrl, EOMI, fundi normal, TMs normal, mastoids non-tender, neck supple, motor neuro exam normal, normal gait, mental status normal

  5. ED Therapy and Work Up • Prochlorperazine 10 mg, by vein Acetaminophen 325/Oxycodone 5, orally • CBC, Chem 7, UCG, CT Head without contrast

  6. ED Diagnostic Results: Visit 1 • WBC count 12.4K • CT head reviewed by ED attending and radiology resident as negative

  7. ED Disposition: Visit 1 • Patient’s pain responded to medications • Patient discharged with prescription for acetaminophen/butalbital/caffeine = Fioricet

  8. Radiology Over-Read: Monday AM(2.5 days since 1st ED visit) • Opacification of the right ethmoid and right sphenoid sinuses with expansion of the sphenoid septations toward the left. • No intracranial disease

  9. ED Discrepancy Procedure • Patient was contacted by phone and informed of sinus problem on CT • Patient went to her PMD that afternoon • PMD discharged her with prescription for levofloxacin

  10. 2nd ED Visit: Tuesday Morning(3.5 days after 1st ED visit) • New onset swelling and severe pain around left eye • Continued, worsening right-sided headache • Slept poorly, confused, hallucinating? • 100/80, 96, 18, 101.9F

  11. Morning Exam: 2nd Visit • Left peri-orbital edema, erythema, proptosis, chemosis, severe pain with EOMs. Left pupil reacted to light. • Ambulated in with normal gait. No obvious motor deficits. • Awake. Followed simple commands, but mildly confused, answering slowly or incorrectly, with difficulty concentrating. • (+) Nuchal rigidity

  12. ED Therapy & Work Up • 2 grams ceftriaxone by vein after cultures • Repeat CT of brain and sinuses with contrast • LP • ID and ENT consults; vancomycin and metronidazole given by vein • Admitted to MICU

  13. Afternoon Exam: 2nd Visit • Deteriorating mental status. • Mild left sided weakness left upper and left lower extremities.

  14. ED Admitting Diagnoses • Orbital Cellulitis • Meningitis • Rule out Cavernous Sinus Thrombosis

  15. Septic Dural Sinus ThrombosisSuppurative Intracranial Thrombophlebitis • Infected venous thrombosis of cortical veins or sinuses • From meningitis, subdural empyema, epidural abscess, infection in the skin of the face, paranasal sinuses, middle ear, mastoid, maxillary teeth or neck. • Iatrogenic cases have been associated with rhinoplasty, hip surgery and oral/dental surgery.

  16. Non-Septic Dural Sinus Thrombosis • Dehydration from vomiting • Hypercoagulable states • Immunologic abnormalities, including the presence of circulating antiphospholipid antibodies

  17. Septic Dural Sinus Thrombosis • Rare; 155 reported cases since 1940 • Cavernous Sinus Thrombosis (CST) is the predominant subset (62%?) • Fulminant, aggressive disease: mortality CST =30%, superior sagittal sinus thrombosis =78% • Morbidity CST: 50% cranial nerve deficit; 17% visually impaired

  18. Infected Thrombus Pathogens • CST: Staphylococcus aureus, other gram-positive organisms, and anaerobes. • Lateral Sinus (otitis media and/or mastoid infection) Proteus species, Escherichia coli, S. aureus, and anaerobes. • Superior Sagittal Sinus (meningitis or air sinus infection) - Streptococcus pneumoniae, S. aureus, other streptococci, and Klebsiella species.

  19. ED Presentation: Superior Sagittal Sinus Thrombosis • Headache, nausea and vomiting, confusion, and focal or generalized seizures. • Rapid development of stupor and coma. • Weakness of the lower extremities with bilateral Babinski signs or hemiparesis is often present.

  20. ED Presentation: Transverse Sinus Thrombosis • Headache and earache. • Gradinego's syndrome: otitis media, sixth nerve palsy, and retro-orbital or facial pain. • Sigmoid sinus and internal jugular vein thrombosis may present with neck pain.

  21. ED Presentation: Cavernous Sinus Thrombosis • Sinusitis, midface infection for 5-10 days. • Fever, headache, malaise, retro-orbital pain and diplopia, which generally precede….. • Ptosis, proptosis, chemosis, eyelid edema, peri-orbital edema and extraocular dysmotility due to deficits of cranial nerves III, IV, and VI. • Hypo- or hyperesthesia of the ophthalmic and maxillary divisions of V, decreased corneal reflex. dilated, tortuous retinal veins and papilledema. • Meningeal signs: nuchal rigidity, Kernig and Brudzinski signs.

  22. Diagnostic Studies • CBC, diff, cultures • Sinus Films, CT, MR, MR Venography, Venous phase cerebral angiogram • LP

  23. ED Management • Antibiotics: S aureus is the usual cause, broad-spectrum coverage for gram-positive, gram-negative, and anaerobic organisms also, pending cultures. • Drain primary source of infection, if feasible (eg, sphenoid sinusitis, facial abscess). • Anticoagulation in carefully selected cases of septic cavernous-sinus thrombosis, not other forms of septic dural-sinus thrombosis. • Urokinase or rtPA? • Corticosteroids?

  24. Consults • ENT • Neurology • ID • Intensive Care

  25. Outcome of Case • Day 1: Seizure, worsening deficit, intubated • Day 2: Heparinized, transient neuro improvement then relapse. • Day 5: Sinuses drained • Day 6: Brain dead • Day 19: Demise

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