Pediatric COVID-19 – Associated Cavernous Sinus Thrombosis

A 14-year-old girl presented to a tertiary pediatric hospital with week-long symptoms of left eye pain, bilateral eye swelling, and subsequent double vision. These symptoms were preceded by a week of coughing, sore throat and congestion. Vital signs were normal except for a temperature of 102°F. Visual acuity was 20/70 dexter oculus (OD, right eye) and 20/25 sinister oculus (OS, left eye). Intraocular pressures were 18 mm Hg OD and 15 mm Hg OS by Tonopen. There was no afferent pupillary abnormality, but the left eye had slow reactivity and restricted extraocular movements. Periorbital edema and erythema were present bilaterally (Figure 1, A), with proptosis (Figure 1, B), chemosis and injection (Figure 1, C) in the left eye. Contrast-enhanced T1-weighted magnetic resonance imaging demonstrated sinusitis and bilateral orbital cellulitis contributing to proptosis (Figure 1, D). Dilatation of the superior ophthalmic vein (The arrow) and an enlarged left cavernous sinus with filling defects (Arrowhead) were also noted and consistent with cavernous sinus thrombosis (CST). Erythrocyte sedimentation rate, C-reactive protein, prothrombin, fibrinogen, D-dimers and factor VIII activity were elevated, while partial thromboplastin time was normal and COVID-19 was positive. The patient received broad-spectrum antibiotics, but cultures produced no organisms. Heparin and steroids began to further reduce thrombosis and inflammation, respectively.

Figure 1. External images show bilateral periorbital edema and erythema (A), proptosis of the left eye (B), and chemosis and injection of the pharmacologically dilated left eye (C). Contrast-enhanced T1-weighted magnetic resonance imaging shows bilateral orbital sinusitis and cellulitis (D) and dilatation of the superior ophthalmic vein (The arrow) and an enlarged left cavernous sinus with filling defects (Arrowhead).

CST occurs as a complication of bacterial sinusitis or orbital cellulitis (1), often associated with underlying hypercoagulability. Cerebral venous sinus thrombosis (2, 3) and CST (4) have been reported in COVID-19 and can occur in younger patients up to 1 week after symptom onset (3) . Sinusitis, orbital cellulitis-induced vascular congestion, and procoagulant effects of COVID-19 likely contributed to the development of CST in this patient.


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