Infectious cavernous sinus thrombosis complicated with meningitis, trigeminal neuralgia and denervation change: a case report

Abstract Background: Cavernous sinus thrombosis is a rare and potentially life-threatening condition that can have various causes. Symptoms of this disorder include headache, reduced visual acuity, focal neurological symptoms, seizures, and cranial nerve deficits, depending on the structures involved. Although rare, sensory and motor trigeminal neuropathy can be an initial presentation of cavernous sinus thrombosis. Case presentation: A 67-year-old female presented with trigeminal neuralgia, followed by tinnitus, vertigo, and trismus. Upon arrival at the emergency department, she also exhibited fever, dizziness, and neck stiffness. The patient had received a tooth implant months before experiencing these symptoms. Initial magnetic resonance imaging revealed homogeneously increased T2 signal and contrast enhancement of bilateral temporalis and masseter muscles, indicating denervation changes of the bilateral trigeminal nerves. Imaging features of basal meningitis and cavernous sinus thrombosis were also noted. Lumbar puncture and laboratory tests were performed, and blood culture revealed Streptococcus intermedius. The patient was diagnosed with meningitis and cavernous sinus thrombosis, complicated by trigeminal neuropathy. She was treated with vancomycin and amoxicillin, and her clinical symptoms greatly improved. Follow-up magnetic resonance imaging studies showed regression of the trigeminal denervation signals. Conclusion: This case report highlights a rare presentation of cavernous sinus thrombosis and basal meningitis, where the initial symptom was trigeminal neuropathy. Denervation changes of the bilateral trigeminal nerves were detected in the MRI study. Therefore, clinicians should be aware that trigeminal neuropathy may be the earliest manifestation of cavernous sinus thrombosis. It is crucial to consider secondary causes of this life-threatening disease to ensure prompt diagnosis and management.