Beyond the hit.

A 53-year old saw mill worker from Mingalardon presented to the medical ward of Insein General Hospital with acute confusion and fever. He noticed diplopia, eye pain, headache,protrusion of the right eye 2 months after injury to left eye. He was taking antipsychotics for mutism and behavioural changes of recent onset. Examination revealed fever, proptosis, right III and VI nerve palsy and rigidity. Baseline investigations show mild anaemia, thrombocytosis, increased inflammatory markers. MRI head revealed enlarged right superior ophthalmic vein dilatation consistent with carotico-cavernous fistula. He was treated for raised intracranial pressure and antibiotics. Anti-psychotics were discontinued. Recovery was uneventful. Mood returned to normal. Only right VI nerve palsy remained. Two lessons were learnt from this case - complex but happy ending. One is rare case of cavernous sinus syndrome and second is the iatrogenic neurological presentation.