Fulminant Aspergillus-Related Cavernous Sinus Thrombosis in an Immunocompetent Intensive Care Unit Patient

Case Report

Austin Crit Care J. 2014;1(1): 3.

Fulminant Aspergillus-Related Cavernous Sinus Thrombosis in an Immunocompetent Intensive Care Unit Patient

Srinivas Rajagopala1*, Sujatha Chandrasekharan2, Sathish Kumar3 and Mohammed Rela4

1Department of Medicine, Jawaharlal Nehru Institute of Postgraduate Medical Education & Research, India

2Department of Microbiology & Serology, Jawaharlal Nehru Institute of Postgraduate Medical Education & Research, India

3Department of Neurology, Jawaharlal Nehru Institute of Postgraduate Medical Education & Research, India

4Department of Hepatobiliary surgery and Liver Transplantation, Global Hospitals and Health City, India

*Corresponding author: Srinivas Rajagopala, Medical Intensive Care Unit, Jawaharlal Nehru Institute of Postgraduate Medical Education & Research, Dhanvantri Nagar, Puducherry, 605006, India

Received: August 12, 2014; Accepted: September 12, 2014; Published: September 15, 2014


We describe an immunocompetent liver trauma patient who developed invasive Aspergillus pneumonia and cavernous sinus thrombosis in the intensive care unit. Invasive mold infection in new niches, including critically ill patients is increasingly being recognized; this case highlights that relative immunodeficiency related to critical illness, massive transfusion and hemorrhage may predispose patients to fulminant mold-related infection. The importance of physical findings such as pupillary asymmetry in critical care is also highlighted.

Keywords: Cavernous sinus thrombosis; Fulminant fungal sinusitis; Invasive aspergillosis; Liver laceration; Immunocompetent adult

Case Presentation

A 29-year old software engineer presented with prostration following blunt injury to the abdomen in a road traffic accident. He was evaluated in another hospital half-an hour after the accident. Examination revealed tachycardia, normal blood pressure and distended abdomen. He was resuscitated with oxygen delivered by face-mask, fluids administered by large-bore peripheral lines and four group-matched whole blood units. Contrast enhanced Computed Tomography (CT) of the abdomen showed extensive liver laceration with hemoperitioneum. CT-head was normal. He was referred to this center for further management. At the initial examination in the emergency of this hospital, the patient was drowsy but oriented (Glasgow coma score 10/15). Pupils were symmetrical, reacting 3 millimeters (mm), without focal neurological deficit. Pulse rate was 128/min, respiratory rate was 26/min, blood pressure was 80/50 and the pulse oximetry saturation was 92%. Abdominal evaluation showed a tense distended abdomen; no peritoneal signs were present. No other fractures or spine injuries were evident. Initial investigations are summarized in Table 1. Review of the CT confirmed the findings and focused screening ultrasonography was normal. Initial management included elective tracheal intubation and ventilation, transfusion to a target of 30 g/dL and emergency laparotomy. Hemostasis was secured and surgical packing of the liver was performed. (Figure1). He subsequently required repeat laparotomy, coil embolization through selective hepatic artery catheterization and activated factor VIIa for control of bleeding. Heparin-free hemodiafiltration for renal failure and ventilation were continued. Empiric piperacillin-tazobactum, pantoprazole, and enteral nutrition were started. On post-operative day 5, new onset of fever, increase in FiO2 requirements and purulent secretions in the endotracheal tube were noted. Respiratory sounds were reduced in the right side. Neurological examination initially showed a non-reactive 6 mm right pupil; the left pupil was 3 mm and reacting to light. Complete restriction of right-sided ocular movements and mild chemosis developed over the next few hours. The left eye and rest of the neurological examination, including fundoscopy, was normal. Rest of the relevant investigations on day 5 was as reported (Table 1). Plain CT-head, performed due to concerns with contrast administration with acute renal failure, did not reveal any infarction or bleeding. Sinus examination showed extensive right-sided pansinusitis with soft-tissue attenuation debris in the nares and sinuses (Figure 2). Chest radiography showed right upper lobe consolidation and collapse. Flexible bronchoscopy revealed purulent secretions with mucosal irregularity of the right upper lobe main bronchus. Bronchoscopic biopsy and lavage was performed. Emergency nasal endoscopic debridement and lavage was performed from the right maxillary, frontal and ethmoid sinuses. Bacterial gram's stain and cultures were sterile. Empiric meropenem, linezolid and liposomal amphotericin B 5 mg/Kg/day were initiated. Magnetic resonance imaging (MRI) of the head without gadolinium contrast was performed (Figure 3). Bronchoscopic biopsy and sinus fluid for fungal stain showed septate hyphae with acute angle branching (Figure 4).