S. MANAZ1R ALI AND S. H. AHMED
Brief Report
Cavernous Sinus Thrombosis in Children by S. Manazir AH, MD, DCH and S. H. Ahmed, MD, DCH Department of Paediatrics, J.N. Medical College, Aligarh Muslim University, Aligarh-202002, India
Introduction
Materials and Methods
Fourteen children admitted with a diagnosis of CST to the paediatric ward of J.N. Medical College, A.M.U. Aligarh during the period May 1985 to June 1988 form the basis of this report. A detailed history was taken with special reference to age and sex of the children, duration of illness, and presenting symptoms. The child was examined for chemosis, proptosis, occular movement, pupil size, meningeal signs, focal neurological deficit, and associated systemic illness. Apart from routine investigation, culture was also sent from blood, conjunctival, and local wound. All the children were given intravenous antibiotics in a combination of: (A) crystalline penicillin + cloxacillin and gentamicin; (B) crystalline penicillin + cloxacillin and chloromycetin; or (C) third generation cephalosporin (Omnatax). The antibiotics were given for a minimum period of 10 days. Anticonvulsants (Dilantin/Phenobarb) were also administered if the child had convulsions. Death or severe neurological deficits were considered as treatment failures.
TABLE 1
Age and sex-wise distribution of cases Sex
S. No.
Age in year
Male
Female
1. 2. 3.
0-1 1-6 6-12
0 2 4
1 1 6
Total Percentage 1 3 10
7.14 21.43 71.43
movement (64 per cent), hemiparesis (29 per cent) and quadriparesis (14 per cent) (Table 2). TABLE 2
Clinical features of CST Clinical features Wound over face Fever Occular pain Vomiting Headache Chemosis Proptosis Ophthalmoplegia Mastoide swelling Altered sensorium Abnormal movement Weakness of limb (a) hemiplegia (b) quadriplegia
No. 14 14 14 14 13 14 14 14 7 12 9 6 4 2
Percentage 100 100 100 100
92.86 100 100 100 50
85.71 64.28 42.85 66.67 33.33
Results
During the period of May 1985 to June 1988 a total of 4544 children were admitted to the paediatric ward. CST was found in 14, i.e. 0.3 per cent (3/1000) of all the admissions. Out of which six were males with a male and female ratio of 1:1.33. Majority of the children (71 per cent) were between 6 and 12 years of age (Table 1). Infected wounds over the danger area of face, fever, occular pain, vomiting, headache, chemosis, proptosis, and ophthalmoplegia were noted in all the cases followed by altered sensorium (86 per cent), abnormal 194
© Oxford University Press 1992
Blood culture, local wound culture and eye swab culture reports are shown in Table 3. The overall positivity rate were 64, 57, and 43 per cent for blood, local swab, and conjunctival swab, respectively. Various types of organisms were isolated. Gram positive cocci (Staph. aureus) and gram negative bacilli constituted 67 and 33 per cent of the isolates from blood, respectively. Similarly, Staph. aureus was grown from 63 and 88 per cent of cultures taken from wound and conjunctival swab, respectively. The mean haemoglobin, white cell count, absolute neutrophil count and Journal of Tropical Pediatrics
Vol. 38
August 1992
Downloaded from http://tropej.oxfordjournals.org/ at New York University on April 13, 2015
Cavernous sinus thrombosis (CST) is a rare bacterial infectious disease of children with high morbidity and mortality in spite of the advances in antibiotic therapy. The current morbidity and mortality statistics are not available in detail. However, the prognosis is always guarded both regarding survival and residual deficit. Hence, it is useful to study the various clinical, haematological, and microbiological parameters of CST in children.
S. MANAZIR ALI AND S. H. AHMED
TABLE 3
Organisms isolated from blood culture, local swab, and eye swab Total
Cultures Blood culture Local swab Eye swab
9 8 6
64.29 57.14 42.86
sedimentation rates of these patients are presented in Table 4.
Mean Mean Mean count Mean
haemoglobin Leucocyte count absolute neutrophil
9.34±0.99gm% 17878.5 ±5369.3 I/cm 13367.64 ±4296.87/cm
ESR (Wintrobe)
29.21 ±12.05 mm in 1ST
Crystalline penicillin, cloxacillin and Gentamicin was administered to 7 of the 14 cases while crystalline penicillin, cloxacillin and chloromycetin was given to another five patients. The remaining two children were treated with third generation cephalosporin (omnatax). All of these received symptomatic treatment for control of raised intra-cranial pressure and convulsion. Eleven patients (79 per cent) died. Their mean duration of stay was 13 hours (range 5-32 hours). The majority of these (82 per cent) died in the first 24 hours. Of the three survivors (21 per cent) two were left with residual paralysis of facial nerve and hemiparesis while the remaining one made a complete recovery with no neurological deficit. Discussion CST is a rare entity in children so the morbidity and mortality statistics are not available.1 However, in our
Journal of Tropical Pediatrics
Vol.38
August 1992
Kleb.
E. coli
6 (66.67%) 5 (62.50%) 5 (83.33%)
2 (22.22) 2 (25.00) 1 (16.67)
1(11.11) 1 (12.50) 0
series the incidence of CST in children was 0.3 per cent (3/1000), with a high mortality. The raised intracranial tension which is frequently present calls for aggressive management. All our children with CST were treated with broad spectrum antibiotics either in combination (crystalline penicillin + cloxacillin + gentamicin), (crystalline penicillin + Cloxacillin + Chloromycetin) or (third generation cephalosporin) for 2 weeks. In conclusion, CST in children though a rare entity is an important cause of morbidity and mortality even after aggressive treatment. It is advocated to treat any superficial infection of the danger area of the face aggressively with broad spectrum antibiotics so that the development of CST can be avoided. References 1. Bell E, William Menezes Arnold DH. Focal Supportive Diseases of the Central Nervous System in Infection in Children. Harper & Row Publishers 1982; 472-4. 2. Miklos A. The cure of cavernous sinus thrombophlebitis. Br J Ophthalmol 1950; 235-239. 3. O'Brien JM, Berney TP. Combined antibiotic therapy of cavernous sinus thrombosis. Connecticut Med J 1951; 15: 908-12. 4. Kelly J, Farrell EJ. Caramide as an adjunct in Staphylococcus albus septicemia with cavernous sinus thrombosis and meningitis. J Pediat, 1959; 39: 486-90. 5. Haas L. Osteomyelitis with cavernous sinus thrombosis in a child with a cure. Br Med J 1955; 245-6. 6. Chigier E. Otogenic meningitis with cavernous sinus thrombosis. S Af Med J 1959; 33: 131-2. 7. Clune JP. Septic thrombosis within the cavernous chamber review of literature with recent advances in diagnosis and treatment. Am J Ophthalmol 1963; 56: 33.
195
Downloaded from http://tropej.oxfordjournals.org/ at New York University on April 13, 2015
TABLE 4
Haematological profile of CST
Staph.
Brief Report
Cavernous Sinus Thrombosis in Children by S. Manazir AH, MD, DCH and S. H. Ahmed, MD, DCH Department of Paediatrics, J.N. Medical College, Aligarh Muslim University, Aligarh-202002, India
Introduction
Materials and Methods
Fourteen children admitted with a diagnosis of CST to the paediatric ward of J.N. Medical College, A.M.U. Aligarh during the period May 1985 to June 1988 form the basis of this report. A detailed history was taken with special reference to age and sex of the children, duration of illness, and presenting symptoms. The child was examined for chemosis, proptosis, occular movement, pupil size, meningeal signs, focal neurological deficit, and associated systemic illness. Apart from routine investigation, culture was also sent from blood, conjunctival, and local wound. All the children were given intravenous antibiotics in a combination of: (A) crystalline penicillin + cloxacillin and gentamicin; (B) crystalline penicillin + cloxacillin and chloromycetin; or (C) third generation cephalosporin (Omnatax). The antibiotics were given for a minimum period of 10 days. Anticonvulsants (Dilantin/Phenobarb) were also administered if the child had convulsions. Death or severe neurological deficits were considered as treatment failures.
TABLE 1
Age and sex-wise distribution of cases Sex
S. No.
Age in year
Male
Female
1. 2. 3.
0-1 1-6 6-12
0 2 4
1 1 6
Total Percentage 1 3 10
7.14 21.43 71.43
movement (64 per cent), hemiparesis (29 per cent) and quadriparesis (14 per cent) (Table 2). TABLE 2
Clinical features of CST Clinical features Wound over face Fever Occular pain Vomiting Headache Chemosis Proptosis Ophthalmoplegia Mastoide swelling Altered sensorium Abnormal movement Weakness of limb (a) hemiplegia (b) quadriplegia
No. 14 14 14 14 13 14 14 14 7 12 9 6 4 2
Percentage 100 100 100 100
92.86 100 100 100 50
85.71 64.28 42.85 66.67 33.33
Results
During the period of May 1985 to June 1988 a total of 4544 children were admitted to the paediatric ward. CST was found in 14, i.e. 0.3 per cent (3/1000) of all the admissions. Out of which six were males with a male and female ratio of 1:1.33. Majority of the children (71 per cent) were between 6 and 12 years of age (Table 1). Infected wounds over the danger area of face, fever, occular pain, vomiting, headache, chemosis, proptosis, and ophthalmoplegia were noted in all the cases followed by altered sensorium (86 per cent), abnormal 194
© Oxford University Press 1992
Blood culture, local wound culture and eye swab culture reports are shown in Table 3. The overall positivity rate were 64, 57, and 43 per cent for blood, local swab, and conjunctival swab, respectively. Various types of organisms were isolated. Gram positive cocci (Staph. aureus) and gram negative bacilli constituted 67 and 33 per cent of the isolates from blood, respectively. Similarly, Staph. aureus was grown from 63 and 88 per cent of cultures taken from wound and conjunctival swab, respectively. The mean haemoglobin, white cell count, absolute neutrophil count and Journal of Tropical Pediatrics
Vol. 38
August 1992
Downloaded from http://tropej.oxfordjournals.org/ at New York University on April 13, 2015
Cavernous sinus thrombosis (CST) is a rare bacterial infectious disease of children with high morbidity and mortality in spite of the advances in antibiotic therapy. The current morbidity and mortality statistics are not available in detail. However, the prognosis is always guarded both regarding survival and residual deficit. Hence, it is useful to study the various clinical, haematological, and microbiological parameters of CST in children.
S. MANAZIR ALI AND S. H. AHMED
TABLE 3
Organisms isolated from blood culture, local swab, and eye swab Total
Cultures Blood culture Local swab Eye swab
9 8 6
64.29 57.14 42.86
sedimentation rates of these patients are presented in Table 4.
Mean Mean Mean count Mean
haemoglobin Leucocyte count absolute neutrophil
9.34±0.99gm% 17878.5 ±5369.3 I/cm 13367.64 ±4296.87/cm
ESR (Wintrobe)
29.21 ±12.05 mm in 1ST
Crystalline penicillin, cloxacillin and Gentamicin was administered to 7 of the 14 cases while crystalline penicillin, cloxacillin and chloromycetin was given to another five patients. The remaining two children were treated with third generation cephalosporin (omnatax). All of these received symptomatic treatment for control of raised intra-cranial pressure and convulsion. Eleven patients (79 per cent) died. Their mean duration of stay was 13 hours (range 5-32 hours). The majority of these (82 per cent) died in the first 24 hours. Of the three survivors (21 per cent) two were left with residual paralysis of facial nerve and hemiparesis while the remaining one made a complete recovery with no neurological deficit. Discussion CST is a rare entity in children so the morbidity and mortality statistics are not available.1 However, in our
Journal of Tropical Pediatrics
Vol.38
August 1992
Kleb.
E. coli
6 (66.67%) 5 (62.50%) 5 (83.33%)
2 (22.22) 2 (25.00) 1 (16.67)
1(11.11) 1 (12.50) 0
series the incidence of CST in children was 0.3 per cent (3/1000), with a high mortality. The raised intracranial tension which is frequently present calls for aggressive management. All our children with CST were treated with broad spectrum antibiotics either in combination (crystalline penicillin + cloxacillin + gentamicin), (crystalline penicillin + Cloxacillin + Chloromycetin) or (third generation cephalosporin) for 2 weeks. In conclusion, CST in children though a rare entity is an important cause of morbidity and mortality even after aggressive treatment. It is advocated to treat any superficial infection of the danger area of the face aggressively with broad spectrum antibiotics so that the development of CST can be avoided. References 1. Bell E, William Menezes Arnold DH. Focal Supportive Diseases of the Central Nervous System in Infection in Children. Harper & Row Publishers 1982; 472-4. 2. Miklos A. The cure of cavernous sinus thrombophlebitis. Br J Ophthalmol 1950; 235-239. 3. O'Brien JM, Berney TP. Combined antibiotic therapy of cavernous sinus thrombosis. Connecticut Med J 1951; 15: 908-12. 4. Kelly J, Farrell EJ. Caramide as an adjunct in Staphylococcus albus septicemia with cavernous sinus thrombosis and meningitis. J Pediat, 1959; 39: 486-90. 5. Haas L. Osteomyelitis with cavernous sinus thrombosis in a child with a cure. Br Med J 1955; 245-6. 6. Chigier E. Otogenic meningitis with cavernous sinus thrombosis. S Af Med J 1959; 33: 131-2. 7. Clune JP. Septic thrombosis within the cavernous chamber review of literature with recent advances in diagnosis and treatment. Am J Ophthalmol 1963; 56: 33.
195
Downloaded from http://tropej.oxfordjournals.org/ at New York University on April 13, 2015
TABLE 4
Haematological profile of CST
Staph.
