Pyrrolidinomethyl tetracycline in cavernous sinus thrombosis.

Before the advent of antibiotics, cavernous sinus thrombosis of septic origin was invariably fatal (Grove, 1936). After the introduction of sulphonamides and antibiotics, Shaw (I 952) collected from the literature sixty cases of cavernous sinus thrombosis in which these drugs were used, and observed that the mortality rate had come down to II 7 per cent., but that 77 per cent. of those who survived showed residual abnormalities. Clune (I963) reported a survival rate of 72 per cent. with a 50 per cent. morbidity rate in those who recovered. In an attempt to reduce the high morbidity rate in survivors, newer antibiotics and anti-inflammatory and anti-thrombotic agents have been tried in various combinations. The present study reports our experience of treating seven cases of septic cavernous sinus thrombosis with pyrrolidinomethyl tetracycline (Reverin). This is a pyrrolidinomethyl derivative of tetracycline with the molecular formula C27H3308N3. It is a water-soluble compound which can be administered intravenously or intramuscularly; it quickly attains high and reliable blood concentrations and the normal intestinal flora are not much affected. After the intravenous injection of 275 mg. Reverin the initial serum concentrations are almost ten times as high as after the oral administration of 250 mg. tetracycline hydrochloride (Strauch and Koch, 1Q58); 8 hours later the former is still almost twice as high as the latter, and even after 24 hours therapeutic blood levels of Reverin can still be demonstrated (Finland, Purcell, Wright, Del Love, Mou, and Kass, 1954). Dimmling, Huner, Lutzeyer, and Simon 1958) have shown that the potency and bacteriostatic range of Reverin is similar to that of tetracycline hydrochloride, but with a much lower general and local toxicity. Because of these advantages, it has been extensively used in fulminating infections with encouraging results, and it is therefore surprising that only one previous report of its use in a case of cavernous sinus thrombosis has been found (Khare, I967). The usual organisms encountered in cases of cavernous sinus thrombosis are the Streptococcus, Staphylococcus, B. proteus, B. pvocyaneus, Pneumococcus, and Meningococcus (Walsh, I957). Tempea and Gorun (I959) stated that the first two organisms were most commonly encountered, and Clune (i963) found Staphylococcus aureus (coagulase-positive) to be the most frequent. Reverin is effective against all these organisms (Finland and others, I954), but sulphonamides and antibiotics, including broad-spectrum tetracycline and chloramphenicol, have not proved to be very effective (Table III, p. I I5).