Bilateral cavernous sinus thrombosis with septic lung lesions resulting from a nasal abscess

A febrile 38-year-old male presented with bilateral proptosis, motility dysfunction, and facial swelling (Fig. 1). The patient was recently treated for a nasal abscess and bacteremia, both positive for methicillin sensitive Staphylococcus aureus (MSSA). Visual acuity was 20/20 in each eye. Brain and orbit imaging revealed bilateral superior ophthalmic vein thromboses, cavernous sinus thromboses (CST), and a surgically inaccessible abscess in left temporalis muscle (Fig. 2). He was started on intravenous (IV) vancomycin 1 g every 12 h and IV heparin 3500 Units every 6 h to achieve PTT between 40 and 60, and on hospital day 13 bridged to therapeutic warfarin 3 mg 5 mg for INR between 2 and 3. Although repeat cultures grew MSSA, given his history of nafcillin intolerance, he was continued on vancomycin. 48 h into admission his orbital process progressed with acute decreased vision to 20/ 100, elevated intraocular pressure and a central retinal artery occlusion left eye. Immediate lateral canthotomy and cantholysis was performed, and one dose of 12 mg IV dexamethasone was given. Despite orbital improvement, on hospital day five, the patient developed fever spikes and altered mental status, leading to