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. 2019 Mar 20;20(1):862.
doi: 10.4102/sajhivmed.v20i1.862. eCollection 2019.

HIV-associated cavernous sinus disease

Cait-Lynn D Wells  1 , Anand A Moodley  2
Affiliations

HIV-associated cavernous sinus disease

Cait-Lynn D Wells et al. South Afr J HIV Med. .

Abstract

Introduction: The underlying diagnosis of cavernous sinus disease is difficult to confirm in HIV-coinfected patients owing to the lack of histological confirmation. In this retrospective case series, we highlight the challenges in confirming the diagnosis and managing these patients.

Results: The clinical, laboratory and radiological data of 23 HIV-infected patients with cavernous sinus disease were analysed. The mean age of patients was 38 years. The mean CD4+ count was 390 cells/μL. Clinically, patients presented with unilateral disease (65%), headache (48%), diplopia (30%) and blurred vision (30%). Third (65%) and sixth (57%) nerve palsies in isolation and combination (39%) were most common. Isolated fourth nerve palsy did not occur. Tuberculosis (17%) was the most commonly identified disorder followed by high-grade B-cell lymphoma (13%), meningioma (13%), metastatic carcinoma (13%) and neurosyphilis (7%). In 22% of the patients, there was no confirmatory evidence for a diagnosis. The patients were either treated empirically for tuberculosis or improved spontaneously when antiretroviral therapy was started. Cerebrospinal fluid was helpful in 4/13 (31%) of patients where it was not contraindicated. Only 3/23 (13%) of the patients had a biopsy of the cavernous sinus mass. The outcomes varied, and follow-up was lacking in the majority of patients.

Conclusion: In HIV-infected patients, histological confirmation of cavernous sinus pathology is not readily available for various reasons. In resource-limited settings, one should first actively search for extracranial evidence of tuberculosis, lymphoma, syphilis and primary malignancy and manage appropriately. Only if such evidence is lacking should a referral for biopsy be considered.

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Conflict of interest statement

The authors declare that they have no financial or personal relationship(s) which may have inappropriately influenced them in writing this article.

Figures

FIGURE 1
FIGURE 1
The cavernous sinus showing cranial nerves III, IV, ophthalmic division of V (V1) and maxillary division of V (V2) along the lateral wall of the sinus. The VI cranial nerve lies free within the sinus. The sympathetic fibres, which enter the cavernous sinus along the carotid artery, are not shown.
FIGURE 2
FIGURE 2
Number of patients presenting with various combinations of third, fourth and sixth cranial nerve palsies.
FIGURE 3
FIGURE 3
Pie chart showing the number of patients and the spectrum of cavernous sinus disease in HIV-infected patients.
FIGURE 4
FIGURE 4
Suggested management algorithm of cavernous sinus disease in an HIV-infected patient.
See this image and copyright information in PMC

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