Superior ophthalmic vein and cavernous sinus thrombosis associated with COVID-19: a case report / Trombose de veia oftálmica superior e seio cavernoso associada à COVID-19: relato de caso

ABSTRACT Cavernous sinus and superior ophthalmic vein thrombosis is a rare clinical condition, and little described in the literature. The clinical presentation is nonspecific and highly variable, and symptoms may include red eye, ophthalmoplegia, coma, and death. The main etiology results from infection of the paranasal sinuses. The final diagnosis must be made through imaging tests such as magnetic resonance imaging. We describe a case of cavernous sinus and superior ophthalmic vein thrombosis after COVID-19 infection in a 64-year-old patient with persistent ocular hyperemia and pain on eye movement. Ophthalmological examination showed preserved visual acuity, conjunctival hyperemia, dilation of episcleral vessels and retinal vascular tortuosity in the right eye. Magnetic resonance imaging confirmed the diagnosis. The association with the COVID-19 was raised, excluding other infectious causes. Enoxaparin and Warfarin were started with significant improvement in the ocular clinical presentation and maintenance of initial visual acuity after 12 months of follow-up.

RESUMO A trombose de seio cavernoso e veia oftálmica superior é uma condição clínica rara e pouco descrita na literatura. A apresentação clínica é inespecífica e altamente variável. Os sintomas podem incluir olho vermelho, oftalmoplegia, coma e morte. A etiologia principal resulta da infecção dos seios paranasais. O diagnóstico final deve ser efetuado por meio de exames de imagem, como ressonância magnética. Descrevemos um caso de trombose de seio cavernoso e veia oftálmica superior após COVID-19 em paciente de 64 anos e com quadro de hiperemia ocular persistente e dor à movimentação ocular. Ao exame oftalmológico, observou-se acuidade visual preservada, hiperemia conjuntival, dilatação de vasos episclerais e tortuosidade vascular retiniana em olho direito. A ressonância confirmou o diagnóstico. A associação com a COVID-19 foi levantada, excluindo-se demais causas infecciosas. Prescrevemos enoxaparina e varfarina, com melhora do quadro clínico ocular e manutenção da acuidade visual inicial após 12 meses de acompanhamento.

Deadly Fungi: Invasive Fungal Rhinosinusitis in the Head and Neck.

Invasive fungal rhinosinusitis (IFRS) is a serious infection that is associated with high morbidity and mortality rates. The incidence of IFRS has been increasing, mainly because of the increased use of antibiotics and immunosuppressive drugs. Rhino-orbital cerebral mucormycosis has recently reemerged among patients affected by COVID-19 and has become a global concern. The detection of extrasinus involvement in its early stage contributes to improved outcomes; therefore, imaging studies are essential in establishing the degree of involvement and managing the treatment properly, especially in immunocompromised patients. The common sites of extrasinus fungal invasion are the intraorbital, cavernous sinus, and intracranial regions. Fungi spread directly to these regions along the blood vessels or nerves, causing devastating complications such as optic nerve ischemia or compression, optic neuritis or perineuritis, orbital cellulitis, cavernous sinus thrombosis, mycotic aneurysm, vasculitis, internal carotid arterial occlusion, cerebral infarction, cerebritis, and brain abscess. IFRS has a broad imaging spectrum, and familiarity with intra- and extrasinonasal imaging features, such as loss of contrast enhancement of the affected region, which indicates tissue ischemia due to angioinvasion of fungi, and the surrounding anatomy is essential for prompt diagnosis and management. The authors summarize the epidemiology, etiology, risk factors, and complications of IFRS and review the anatomy and key diagnostic imaging features of IFRS beyond the sinonasal regions. ©RSNA, 2022.

Radiographic and Clinical Analysis of Cranio-Maxillofacial Complications of Cavernous Sinus Thrombosis Among 256 COVID-19 Patients.

BACKGROUND: A heavy burden of cranio-maxillofacial complications may be encountered in corona virus disease-2019 patients due to the associated coagulopathy and inflammatory consequences of the disease. This study aims to describe clinical and radiographic features of these complications in 256 patients who developed 1 or more of the following complications: cavernous sinus thrombosis, osteomyelitis or necrosis of the jaws. METHODS: Clinical assessment of cranial nerve function and general clinical assessment were performed. Imaging techniques used were multi-slice computed tomography, magnetic resonance imaging, and MRI with contrast enhancement. RESULTS: Thromboembolism of brain and facial blood vessels were associated with inflammation and necrosis. Multi-slice computed tomography/MR angiography showed thrombotic occlusions of the internal carotid artery in the area of the cavernous sinus, and in the ophthalmic veins. Cavernous sinus thrombosis was attributed to coagulopathy and, inflammation of the paranasal sinuses, especially sphenoiditis. A noticeable increase in the size of the cavernous sinus was detected. Compression of the cranial nerves in the cavernous sinus (CS) region causes dysfunction and pathology in the corresponding regions.

Cavernous Sinus Thrombosis and Blindness After Simple Tooth Extraction in Patient Who Recovered From Coronavirus 2019: A Case Report.

The pandemic Coronavirus 2019 is a disease transmitted either by droplets from a person's sneeze or cough or direct spread; also known as severe acute respiratory syndrome coronavirus-2. Although the morbidity of the disease is mainly related to respiratory distress, the associated inflammatory response can induce various coagulopathies despite an anticoagulant therapy. The authors are documenting a case of a diabetic patient who recovered from Coronavirus 2019 and is on prophylactic anticoagulant therapy after routine extraction of a maxillary second molar that progressed to unilateral cavernous sinus thrombosis and loss of vision.

COVID-19 Associated Rhino-Orbito-Cerebral Mucormycosis : A Single Tertiary Care Center Experience of Imaging Findings in COVID-19 Associated Mucormycosis with A Special Focus on the Intracranial Manifestations of Mucormycosis. (preprint)

Context: The current COVID-19 pandemic and mucormycosis epidemic in India has made research on radiological findings of COVID-19 associated mucormycosis imperative. Aim: To describe the imaging findings in COVID-19 associated mucormycosis with a special focus on the intracranial manifestations. Materials: and methods: MRI scans of all patients with laboratory proven mucormycosis and post COVID-19 status, over a period of two months, at an Indian Tertiary Care Referral Centre, were retrospectively reviewed and descriptive statistical analysis was carried out. Results: : 58 patients (47 men and 11 women) were evaluated. Deranged blood glucose levels were observed in 81% of cases. Intracranial invasion was detected in 31 patients (53.4%). The most common finding in cases with intracranial invasion was pachymeningeal enhancement (90.3% i.e., 28/31). This was followed by infarcts (17/31 i.e., 55%), cavernous sinus thrombosis (11/58 i.e., 18.9%), fungal abscesses (11/31 i.e., 35.4%), and intracranial hemorrhage (5/31 i.e., 16.1% cases). Perineural spread was observed in 21.6% (11/51) cases.Orbital findings included extraconal fat and muscle involvement, intraconal involvement, orbital apicitis, optic neuritis, panophthalmitis, and orbital abscess formation in decreasing order of frequency. Cohen’s kappa coefficient of inter-rater reliability for optic nerve involvement and cavernous sinus thrombosis was 0.7. Cohen’s coefficient value for all other findings was 0.8-0.9. Conclusions: : COVID-19 associated Rhinocerebral mucormycosis has a plethora of orbital and intracranial manifestations. MRI, with its superior soft-tissue resolution, is the imaging modality of choice to expedite the initial diagnosis, accurately map out disease extent, and for prompt identification and scrupulous management of its complications.

Cavernous Sinus Thrombosis in COVID-19 Associated Rhino-Orbital Mucormycosis: A Retrospective Audit in the First Wave of the Pandemic (preprint)

Purpose: Cavernous sinus thrombosis (CST) is a complication of rhino-orbital-cerebral mucormycosis. The COVID-19 pandemic saw a rapid surge in the cases of acute fungal sinusitis, many of whom also had CST, further contributing to the ophthalmoplegia. This study was a retrospective audit of patients with mucormycosis treated during the first wave of the COVID-19 pandemic. Methods: This study was conducted at a tertiary referral centre, and patients with rhino-orbital mucormycosis were included. Relevant laboratory investigations and CT scans of the paranasal sinuses and the cavernous sinus were analysed. Mortality at discharge was calculated. Results: 61 cases of invasive mucormycosis were seen, of whom 20 were COVID-19 positive, and 21 had radiological evidence of CST. All patients in the study initially presented with clinical suspicion of mucormycosis, and COVID-19 was diagnosed during pre-admission investigations. 93% of patients had diabetes. A majority of patients received Amphotericin B and surgical debridement. The sphenoid sinus was involved in 32(52%) patients and the orbit in 34(56%). Factors affecting CST, such as platelet counts, were studied. Fifteen (25%) patients succumbed during their treatment. Conclusions: 34.4% of patients with mucormycosis developed CST. Being COVID-19 positive led to an increase in mortality; however, there was no significant increase in death due to simultaneous COVID-19 and CST. Sinus involvement was not significant for the development of CST.

Cavernous sinus thrombosis with central retinal artey occlusion in COVID-19: A case report and review of literature.

Coronavirus disease-2019 (COVID-19) is showing a wide spectrum of ocular manifestations. They are creeping from vision sparing to irreversible visual loss as a result of its thromboembolic events. Hypercoagulability associated with COVID-19 is also called "sepsis-induced coagulopathy" and may predispose to thromboembolic phenomenon that decides the morbidity and mortality of this pandemic. A 37-year-old man presented with no perception of light in the left eye with optic atrophy and macular pucker on fundus examination. Visual evoked potential showed extinguished P 100 wave. His past medical history revealed severe pneumonia secondary to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV 2) infection about 3 months back.

Clinical Characteristics of Venous Thromboembolism in COVID-19 Patients Admitted to intensive care unit (preprint)

Introduction: COVID-19 infection was associated with many morbid conditions, one of which is venous thromboembolism; however, this is varied in incidence and clinical characteristics, with no known definite risk predictors. Aim: To identify the incidence, clinical characteristics, and risks and outcome of venous thromboembolism in COVID-19 patients. Methods: : a retrospective cohort study comparing the recorded data for two groups of patients with confirmed COVID-19 infection and admitted to the ICU in 6 months duration. Results: : the incidence of venous thromboembolism was 30%, where pulmonary embolism (PE) alone was the most frequent type (68.2%), followed by, DVT with PE (15.1%), DVT alone (12.1%), cavernous sinus thrombosis alone CST (3%) and the least frequency was CST with renal artery thrombi (1.5%). Smoking and malignancy were more frequent in VTE group with more statistically significant elevation of D dimer. the pulmonary embolism was lobar in the majority of our patients (69.6%), followed by segmental (17.9%), while the least frequency was for massive pulmonary embolism (12.5%). Conclusion: VTE is a common event in COVID-19 patients, where smoking and malignancy more frequent, D dimer is significantly elevated, and more morbidity and mortality in those patients.