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A difficult case
Actinomyces cavernous sinus infection: a case and systematic literature review
  1. Michal Lubomski1,2,
  2. James Dalgliesh3,
  3. Kenneth Lee4,
  4. Omprakash Damodaran5,
  5. Genevieve McKew6,7,
  6. Stephen Reddel1,7
  1. 1Department of Neurology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
  2. 2School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
  3. 3Department of Ophthalmology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
  4. 4Department of Anatomical Pathology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
  5. 5Department of Neurosurgery, Concord Repatriation General Hospital, Concord, New South Wales, Australia
  6. 6Department of Infectious Disease, Concord Repatriation General Hospital, Concord, New South Wales, Australia
  7. 7Concord Clinical School, The University of Sydney, Concord Repatriation General Hospital, Concord, New South Wales, Australia
  1. Correspondence to Dr Michal Lubomski, Department of Neurosciences, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2139, Australia; michal.lubomski{at}nd.edu.au

Abstract

A 63-year-old man presented with a 2-month history of progressive right-sided exophthalmos, painful ophthalmoplegia and fevers. As more features developed, he was diagnosed with giant cell arteritis, then Tolosa-Hunt syndrome, and transiently responded to corticosteroids. A bland cerebrospinal fluid and highly metabolically active brain (18F)-fluoro-D-glucose-positron emission tomography suggested lymphoma. Biopsy of the mass showed sulphur granules with Gram-positive filamentous bacteria with Actinomyces-like colonies. Actinomyces cavernous sinus infections are rare and indolent. They often mimic non-infective causes including other inflammatory and infiltrative conditions, vascular and neoplastic causes, particularly lymphoma. Clinicians should consider infective cavernous sinus syndromes in people with a fluctuating painful ophthalmoplegia that responds poorly to corticosteroids. The term Tolosa-Hunt syndrome is problematic and should be retired or used only with reservation.

  • actinomyces
  • cavernous sinus
  • ophthalmoplegia
  • infection
  • tolosa-hunt syndrome

https://doi.org/10.1136/practneurol-2017-001844

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    Footnotes

    • Contributors ML and SR were involved in the study concept and literature review. KL was involved in the review and reporting of the histopathology. OD was the neurosurgeon performing the biopsy. GMK and SR supervised the research project. ML, JD, OD, GMK and SR were involved in the patient’s clinical management. All authors were involved in the writing of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed by Dilraj Sokhi, Kenya, Africa, and Christian Lueck, Canberra, Australia.

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      Practical Neurology 2018; 18 347-347 Published Online First: 17 Sep 2018. doi: 10.1136/practneurol-2018-002077
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      Time to retire the Tolosa-Hunt syndrome?
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