Objective:

This abstract presents a challenging clinical case of a 63-year-old woman with bacterial meningitis who was incidentally found to have complete and bilateral cavernous sinus thrombosis (CST) in the absence of symptoms (i.e cranial nerve deficits). The primary objective of this study is to discuss the management dilemma between anticoagulation and conservative treatment (antibiotics) in such cases.

Background:

Patient is a 63 year-old-woman presented with altered mental status, progressive for two weeks. Lab evaluation is positive for bacteremia with gram positive rods. Physical examination is positive only for altered mentation, and meningeal signs. Meningitis confirmed with CSF studies. MR brain W/ contrast positive for complete and bilateral Cavernous-sinus-thrombosis, along with scattered punctate ischemic infarcts.  

Design/Methods:

N/A

Results:

The management of this unique case posed a challenging dilemma, as the patient's bacterial meningitis warranted prompt antibiotic therapy, but the CST raised concerns about potential complications if anticoagulation were initiated. After careful consideration (potential septic emboli, risk of bleeding etc), it was decided to prioritize the treatment of bacterial meningitis with intravenous antibiotics while closely monitoring the patient's clinical condition. Serial imaging with MRI and frequent neurological assessments were performed to assess the progression of CST which completely resolved with antibiotics only. 

Conclusions:

This case emphasizes the clinical challenge of managing septic, complete and bilateral cavernous sinus thrombosis in the setting of bacterial meningitis. The decision to withhold anticoagulation was made reluctantly. Patient was monitored careful with low-thresh-hold for anticoagulation initiation. The patient was successfully treated for bacterial meningitis without developing symptomatic complications related to the CST. This case underscores the need for ongoing investigation regarding the treatment dilemma of septic CST.