CASE REPORT Septic thrombosis of the cavernous sinus secondary to a Streptococcus milleri oral infection B Imholz 1 , M Becker 2 , T Lombardi 3 and P Scolozzi* ,1 1 Service of Oral and Maxillofacial Surgery, Department of Surgery, Ho ˆpitaux Universitaire de Gene `ve, Faculty of Medicine, Gene `ve, Switzerland; 2 Division of Radiology, Ho ˆpitaux Universitaire de Gene `ve, Faculty of Medicine, Gene `ve, Switzerland; 3 Laboratory of Oral Histopathology, Division of Stomatology, Ho ˆpitaux Universitaire de Gene `ve, Faculty of Medicine, Gene `ve, Switzerland Septic thrombosis of the cavernous sinus (STCS) is an uncommon and potentially lethal disease. Sphenoid and ethmoid sinusitis followed by facial cutaneous infections represents the most common aetiologies, with Staphylococcus aureus as the main responsible organism followed by the Streptococcus pneumoniae. Although all infectious foci of the head and neck area can potentially spread to the cavernous sinus, STCS from oral infection is an exceptionally rare occurrence. We report the unusual case of a patient who presented with an acute STCS secondary to a generalized Streptococcus milleri periodontitis. This case high- lights the importance of systematically performing a detailed examination of the oral cavity in patients presenting with intracranial infections caused by uncommon pathogens such as the Streptococcus milleri group. Dentomaxillofacial Radiology (2012) 41, 525–528. doi: 10.1259/dmfr/33011853 Keywords: cavernous sinus thrombosis; oral infection; Streptococcus milleri Introduction Septic thrombosis of the cavernous sinus (STCS) is a pathological entity that has almost disappeared, but in the pre-antibiotic era it had a mortality rate of almost 100%. 1,2 Nevertheless, temporary or devastating defi- nitive neurological sequelae are still encountered in up to 20% of cases. 1,2 Given its intracranial ‘‘crossroads’’ position between the cerebral and the florid facial venous network, all infectious foci of the head and neck area can potentially spread to the cavernous sinus and give rise to a septic thrombosis. Fever, ptosis, proptosis, chemosis and extraocular muscle palsy are the most common presenting clinical signs and symptoms. 1,2 High-resolution CT and MRI imaging have largely contributed to improved detection of the disease at an early stage and have become the gold standard for radiological diagnosis. We report the unusual case of a patient who presented with an acute STCS related to a Streptococcus milleri infection secondary to a severe chronic periodontitis. To the best of our knowledge, no other similar cases have previously been reported. Case report A 45-year-old Cambodian male was admitted to the Emergency Department of the Ho ˆpitaux Universitaires de Ge `neve, Geneva, Switzerland, in December 2008 with a 1 week history of a rapidly appearing bilateral fronto- temporal headache. The diagnosis of rhinosinusitis was made. 3 days later, he presented with a worsening headache associated with facial and dental pain, left eyelid swelling and a fever. Clinical examination revealed a tender, warm and fluctuant tumefaction of the upper left eyelid. Oral examination revealed generalized and severe periodontitis. He was febrile (39 u C), tachycardic (100 beats min –1 ) and had mild hypertension (150/ 100 mm Hg). The neurological and ophthalmological examinations were normal. The white cell count was elevated at 15 500 mm –3 and the C-reactive protein at 301.1 mg l –1 . The panoramic radiograph demonstrated extensive loss of the alveolar bone support of all teeth (a ‘‘floating teeth’’ appearance), confirming the diagnosis *Correspondence to: Dr Paolo Scolozzi, Service of Oral and Maxillofacial Surgery, Department of Surgery, Ho ˆ pitaux Universitaire de Gene `ve, Faculty of Medicine, 1211 Gene `ve, Switzerland. E-mail: [email protected] Received 8 November 2010; revised 2 January 2011; accepted 3 January 2011 Dentomaxillofacial Radiology (2012) 41, 525–528 ’ 2012 The British Institute of Radiology http://dmfr.birjournals.org
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