Management of Cavernous Sinus Thrombosis Following Herpes Zoster Ophthalmicus

Abstract

Herpes zoster opthalmicus (HZO) is the reactivation of latent varicella zoster virus (VZV) within the ophthalmic branch of the trigeminal ganglion (V1). Common complications are postherpetic neuralgia and vasculopathy. Here, we report a rare case of a 47-year-old female presenting with HZO and aseptic cavernous sinus thrombosis (CST). Early screening for rare and deadly complications such as CST using CT cerebral venography (CTV) and magnetic resonance venography (MRV), as was done, is crucial to detection at earlier stages when intervention is most effective. Anticoagulation therapy was promptly started, and the patient's symptoms continued to improve during the hospital stay.

Keywords: aseptic cavernous sinus thrombosis; herpes simplex; herpes simplex ophthalmicus; herpes zoster meningitis; varicella-zoster virus.

Figure 1. Contrast-enhanced CT orbits in axial (A) plane demonstrating asymmetric swelling and enhancement of the right preseptal periorbital soft tissues (arrowheads) and right cornea (arrow) compared to left, and coronal (B) plane showing asymmetric swelling and enhancement of the right lacrimal gland (thick arrow).

Figure 2. MRI of the cavernous sinuses were obtained including axial postcontrast 3DT1 space (A and D), coronal T2 fat saturated (B and C), coronal postcontrast T1 (E) and coronal postcontrast T1 subtracted from pre-contrast (F) images. There is asymmetric swelling and enhancement of the right pre-septal orbital soft tissues (arrowheads on A) and right cornea (arrow on A). There is asymmetric swelling and enhancement of the right intra-orbital fat (arrowhead on B and F) and right sided rectus muscles particularly involving the lateral rectus (long arrow on C and F) and medial rectus muscles (short arrow on C and F) as well as right lacrimal gland (thick arrow on B). There is evidence of intracranial extension with subtle asymmetric enhancement of the cisternal segment of the right trigeminal nerve (arrow on D) as well as asymmetric meningeal enhancement of the lateral wall of the right cavernous sinus (long arrow on E) and right Meckel’s cave (short arrow on E).

Figure 3. Subtracted axial (A) and coronal (B) maximum intensity projection imaging of the contrast-enhanced CTV demonstrates asymmetric filling defect and hypo-enhancement in the right cavernous sinus (thick arrow on A and B) and petrosal sinus (arrow on A) compared to left compatible with thrombosis. The remaining dural sinuses including transverse sinuses (arrowheads on A) and superior sagittal sinus (arrowhead on B) are patent.

CTV: computerized tomography venography

Figure 4. Appearance on day three of IV antiviral therapy.

Figure 5. Appearance on day seven of admission.