Scientific letter
Cavernous sinus thrombosis due to invasive community-associated methicillin-resistant staphylococcus aureus infection
Trombosis del seno cavernoso debido a infección por Staphylococcus aureus meticilin resistente asociado a la comunidad
Sergi César
, Aitana García, Ester Parada, Antoni Soriano
Corresponding author
Department of Pediatrics, Hospital Universitari Joan XXIII, Tarragona, Spain
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"documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Enferm Infecc Microbiol Clin. 2010;28:753-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4656 "formatos" => array:3 [ "EPUB" => 8 "HTML" => 4210 "PDF" => 438 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "Aparición de sintomatología neurológica durante el tratamiento de la tuberculosis: descripción de dos casos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "753" "paginaFinal" => "755" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Onset of neurological symptoms during tuberculosis treatment: description of two cases" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2069 "Ancho" => 1625 "Tamanyo" => 239987 ] ] "descripcion" => array:1 [ "es" => "<p class="elsevierStyleSimplePara elsevierViewall">(a) Lesiones nodulares en cisternas supraselar y silvianas. (b) Lesiones parenquimatosas supra e infratentoriales subcorticales y en bulbo raquídeo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luis Arquinio, Mercedes García-Gasalla, Inés Losada, Helena Sarasibar" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Luis" "apellidos" => "Arquinio" ] 1 => array:2 [ "nombre" => "Mercedes" "apellidos" => "García-Gasalla" ] 2 => array:3 [ "Iniciales" => "I." "nombre" => "Inés" "apellidos" => "Losada" ] 3 => array:2 [ "nombre" => "Helena" "apellidos" => "Sarasibar" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X10001953?idApp=UINPBA00004N" "url" => "/0213005X/0000002800000010/v1_201305090151/S0213005X10001953/v1_201305090151/es/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Cavernous sinus thrombosis due to invasive community-associated methicillin-resistant <span class="elsevierStyleItalic">staphylococcus aureus</span> infection" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "755" "paginaFinal" => "756" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sergi César, Aitana García, Ester Parada, Antoni Soriano" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Sergi" "apellidos" => "César" "email" => array:1 [ 0 => "sergi.cesar@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor1" ] ] ] 1 => array:2 [ "nombre" => "Aitana" "apellidos" => "García" ] 2 => array:2 [ "nombre" => "Ester" "apellidos" => "Parada" ] 3 => array:2 [ "nombre" => "Antoni" "apellidos" => "Soriano" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Department of Pediatrics, Hospital Universitari Joan XXIII, Tarragona, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trombosis del seno cavernoso debido a infección por Staphylococcus aureus meticilin resistente asociado a la comunidad" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 980 "Tamanyo" => 135698 ] ] "descripcion" => array:1 [ "en" => "<p class="elsevierStyleSimplePara elsevierViewall">MRI after 8 weeks of treatment: no evidence of right sinus cavernous thrombosis, with pseudoaneurysm of the right intracavernous carotid artery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p class="elsevierStylePara elsevierViewall">A previously healthy 9-year-old girl, born in Colombia and living in Spain for the last two years was admitted to our hospital with a 5-day history of fever and shivers. Physical examination at admission showed a sick-appearing girl, with nuchal rigidity, respiratory distress and a furuncle on her right shoulder. Bilateral peripheral nodular infiltrates were seen on chest X-ray. Laboratory results revealed neutrophilia, microcytic anemia, hyponatremia, C-reactive protein level of 20.6<span class="elsevierStyleHsp" style=""></span>mg/dL and infectious consumption coagulopathy. Cerebrospinal fluid (CSF) examination was normal. A diagnosis of bacteriemia with pneumonia was suspected, and cefotaxime was started. Community-associated methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> (CA-MRSA) grew in the blood culture. Genetic molecular analysis detected the Panton-Valentine leukocidin gene. Vancomycin was added to the initial treatment, but was changed to teicoplanin due to an allergic reaction. The patient was discharged on day 8, with clindamycin and cefuroxime treatment, but 20<span class="elsevierStyleHsp" style=""></span>h later was readmitted with right ptosis, sixth cranial nerve palsy, and worsening headache. Cerebral magnetic resonance imaging (MRI) showed right cavernous sinus thrombosis and intracavernous internal carotid artery arteritis. Chest CT scan evidenced bilateral necrotized peripheral nodules, apparently corresponding to septic emboli. Retinal examination and echocardiography were normal. Cefotaxime and teicoplanin were reinitiated and enoxaparin and oral acenocoumarol were added. On day 14 teicoplanin was switched to linezolid because the patient showed no clinical improvement, and was completed at 8 weeks. Four months after discharge, MRI demonstrated an absence of thrombosis and a pseudoaneurysm-like image at the intracavernous right carotid artery (<a class="elsevierStyleCrossRef" href="#fig1">Fig. 1</a>). The latest MRI, 8 months after discharge, showed a significant improvement, with a residual image of the pseudoaneurysm detected in the previous MRI. In the study of contacts, two members of her family proved to be MRSA carriers.</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p class="elsevierStylePara elsevierViewall">MRSA is an emergent pathogen and the most common cause of skin and soft tissue infections. In 2005, the estimated incidence rate of invasive infection by this pathogen in the United States was 31.8 per 100 000.<a class="elsevierStyleCrossRef" href="#bib1"><span class="elsevierStyleSup">1</span></a> Panton-Valentine leukocidin is a cytolytic toxin produced by CA-MRSA and is associated with furuncles and necrotizing pneumonia,<a class="elsevierStyleCrossRefs" href="#bib2"><span class="elsevierStyleSup">2,3</span></a> as was seen in our case. In 2008, 4 cases of MRSA (21% of all <span class="elsevierStyleItalic">S. aureus</span> infections<span class="elsevierStyleItalic">)</span> were isolated in our pediatric department and two corresponded to bacteriemia.</p><p class="elsevierStylePara elsevierViewall">Cerebral sinus thrombosis mainly affects immunocompromised patients or patients with acquired prothrombotic conditions, but can also affect children, as has been reviewed by DeVeber and Wasay.<a class="elsevierStyleCrossRefs" href="#bib4"><span class="elsevierStyleSup">4,5</span></a> Our patient was a previously healthy child without prothrombotic conditions and no infection in the area responsible for venous drainage of the cavernous sinuses. MRI is the most sensitive and specific examination technique for this disease, since contrast-enhanced computed tomography (CT) will miss diagnostic features in about 40% of patients.<a class="elsevierStyleCrossRef" href="#bib4"><span class="elsevierStyleSup">4</span></a> Antibiotics have had the greatest impact on the prognosis of septic cavernous sinus thrombosis. When MRSA is isolated, high doses of vancomycin, teicoplanin or linezolid are recommended.<a class="elsevierStyleCrossRef" href="#bib6"><span class="elsevierStyleSup">6</span></a> Anticoagulant treatment in adults appears to be safe and is associated with a potentially substantial reduction in the risk of death, which does not reach statistical significance according to a Cochrane review.<a class="elsevierStyleCrossRef" href="#bib7"><span class="elsevierStyleSup">7</span></a> A trial conducted by deVeber in pediatric patients also concluded that low molecular weight heparin may play a role in the treatment of sinus venous thrombosis.<a class="elsevierStyleCrossRef" href="#bib8"><span class="elsevierStyleSup">8</span></a> We treated our patient with low molecular weight heparin because of progression of the local symptoms, despite effective antibiotic therapy (resolution of fever and respiratory symptoms).</p><p class="elsevierStylePara elsevierViewall">To our knowledge, this is the first reported case of cavernous sinus thrombosis caused by CA-MRSA in a child as a complication of a distant infection, although previous reports of invasive MRSA affecting the cavernous sinus have been described in adults.<a class="elsevierStyleCrossRefs" href="#bib9"><span class="elsevierStyleSup">9,10</span></a> The pediatric population may be affected when an adult, usually a family member, is a carrier of the microorganism. Considering the high morbidity and mortality related to this disease, the favorable recovery achieved in this patient is noteworthy.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 980 "Tamanyo" => 135698 ] ] "descripcion" => array:1 [ "en" => "<p class="elsevierStyleSimplePara elsevierViewall">MRI after 8 weeks of treatment: no evidence of right sinus cavernous thrombosis, with pseudoaneurysm of the right intracavernous carotid artery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Invasive methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> infections in the United States" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.M. 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| 2021 August | 121 | 14 | 135 |
| 2021 July | 96 | 14 | 110 |
| 2021 June | 93 | 13 | 106 |
| 2021 May | 142 | 10 | 152 |
| 2021 April | 230 | 32 | 262 |
| 2021 March | 107 | 12 | 119 |
| 2021 February | 128 | 8 | 136 |
| 2021 January | 120 | 17 | 137 |
| 2020 December | 101 | 11 | 112 |
| 2020 November | 98 | 13 | 111 |
| 2020 October | 72 | 4 | 76 |
| 2020 September | 71 | 10 | 81 |
| 2020 August | 80 | 9 | 89 |
| 2020 July | 65 | 4 | 69 |
| 2020 June | 57 | 9 | 66 |
| 2020 May | 50 | 11 | 61 |
| 2020 April | 47 | 4 | 51 |
| 2020 March | 55 | 14 | 69 |
| 2020 February | 58 | 6 | 64 |
| 2020 January | 57 | 9 | 66 |
| 2019 December | 44 | 10 | 54 |
| 2019 November | 30 | 9 | 39 |
| 2019 October | 36 | 9 | 45 |
| 2019 September | 88 | 8 | 96 |
| 2019 August | 106 | 1 | 107 |
| 2019 July | 129 | 17 | 146 |
| 2019 June | 183 | 20 | 203 |
| 2019 May | 267 | 20 | 287 |
| 2019 April | 216 | 23 | 239 |
| 2019 March | 191 | 3 | 194 |
| 2019 February | 144 | 10 | 154 |
| 2019 January | 188 | 2 | 190 |
| 2018 December | 121 | 2 | 123 |
| 2018 November | 29 | 5 | 34 |
| 2018 October | 93 | 8 | 101 |
| 2018 September | 118 | 6 | 124 |
| 2018 August | 30 | 7 | 37 |
| 2018 July | 40 | 8 | 48 |
| 2018 June | 28 | 5 | 33 |
| 2018 May | 57 | 15 | 72 |
| 2018 April | 74 | 1 | 75 |
| 2018 March | 67 | 2 | 69 |
| 2018 February | 38 | 1 | 39 |
| 2018 January | 82 | 1 | 83 |
| 2017 December | 69 | 0 | 69 |
| 2017 November | 79 | 3 | 82 |
| 2017 October | 81 | 2 | 83 |
| 2017 September | 62 | 1 | 63 |
| 2017 August | 46 | 4 | 50 |
| 2017 July | 46 | 2 | 48 |
| 2017 June | 78 | 12 | 90 |
| 2017 May | 61 | 6 | 67 |
| 2017 April | 61 | 2 | 63 |
| 2017 March | 99 | 37 | 136 |
| 2017 February | 163 | 4 | 167 |
| 2017 January | 36 | 0 | 36 |
| 2016 December | 46 | 5 | 51 |
| 2016 November | 65 | 3 | 68 |
| 2016 October | 91 | 13 | 104 |
| 2016 September | 77 | 8 | 85 |
| 2016 August | 48 | 7 | 55 |
| 2016 July | 32 | 3 | 35 |
| 2016 June | 53 | 9 | 62 |
| 2016 May | 40 | 1 | 41 |
| 2016 April | 45 | 7 | 52 |
| 2016 March | 41 | 9 | 50 |
| 2016 February | 69 | 18 | 87 |
| 2016 January | 68 | 15 | 83 |
| 2015 December | 64 | 14 | 78 |
| 2015 November | 60 | 9 | 69 |
| 2015 October | 61 | 16 | 77 |
| 2015 September | 55 | 17 | 72 |
| 2015 August | 72 | 9 | 81 |
| 2015 July | 136 | 1 | 137 |
| 2015 June | 94 | 5 | 99 |
| 2015 May | 135 | 8 | 143 |
| 2015 April | 197 | 19 | 216 |
| 2015 March | 194 | 4 | 198 |
| 2015 February | 161 | 2 | 163 |
| 2015 January | 113 | 3 | 116 |
| 2014 December | 150 | 6 | 156 |
| 2014 November | 178 | 1 | 179 |
| 2014 October | 162 | 4 | 166 |
| 2014 September | 113 | 1 | 114 |
| 2014 August | 93 | 2 | 95 |
| 2014 July | 102 | 3 | 105 |
| 2014 June | 117 | 2 | 119 |
| 2014 May | 87 | 2 | 89 |
| 2014 April | 83 | 3 | 86 |
| 2014 March | 171 | 10 | 181 |
| 2014 February | 183 | 30 | 213 |
| 2014 January | 183 | 9 | 192 |
| 2013 December | 180 | 6 | 186 |
| 2013 November | 202 | 7 | 209 |
| 2013 October | 194 | 7 | 201 |
| 2013 September | 172 | 11 | 183 |
| 2013 August | 184 | 9 | 193 |
| 2013 July | 207 | 16 | 223 |
| 2013 June | 153 | 4 | 157 |
| 2013 May | 136 | 4 | 140 |
| 2013 April | 99 | 8 | 107 |
| 2013 March | 100 | 9 | 109 |
| 2013 February | 67 | 5 | 72 |
| 2013 January | 46 | 4 | 50 |
| 2012 December | 59 | 1 | 60 |
| 2012 November | 21 | 3 | 24 |
| 2012 October | 6 | 2 | 8 |
| 2010 December | 1320 | 0 | 1320 |
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