Case presentation

A 37-year-old athletic black man consulted for headache, diplopia and photophobia. His symptoms had started 15 days earlier with fever, rhinorrhoea, tearing and right eye swelling associated with bilateral conjunctival hyperaemia, exophthalmos, decreased visual acuity and bilateral limitation of lateral gaze. Investigations in an African hospital showed hyperleucocytosis and increased erythrocyte sedimentation rate. MR brain scan showed ethmoidal sinusitis and bilateral orbital cellulitis. He received a 7-day course of intravenous ceftriaxone and vancomycin, together with intravenous corticosteroids. He was transferred to Switzerland for further management.

On examination, there was right-sided exophthalmos, chemosis and conjunctival erythema, with bilaterally limited lateral gaze and decreased visual acuity (4/10 for each eye). Tests for HIV, diabetes mellitus, connective tissue diseases, antiphospholipid antibodies and other prothrombotic factors were negative. Cerebrospinal fluid (CSF) analysis showed increased protein and white cell count. Bacteriological analysis of blood, CSF and sinus biopsies was negative. A CT scan of head showed ethmoidosphenoidal sinusitis, bilateral orbital cellulitis with fluid collection in the right lateral rectus muscle and thrombosis in the left sigmoid sinus (figure 1).