Page 213 - SAHCS HIVMed Journal Vol 20 No 1 2019

Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Page 1 of 7 Original Research

HIV-associated cavernous sinus disease

Authors: Introduction: The underlying diagnosis of cavernous sinus disease is difficult to confirm in HIV-
Cait-lynn D. Wells coinfected patients owing to the lack of histological confirmation. In this retrospective case series,
1
Anand A. Moodley 2
we highlight the challenges in confirming the diagnosis and managing these patients.
Affiliations: Results: The clinical, laboratory and radiological data of 23 HIV-infected patients with
1 Department of Neurology,
Greys Hospital, University cavernous sinus disease were analysed. The mean age of patients was 38 years. The mean
of KwaZulu-Natal, CD4+ count was 390 cells/µL. Clinically, patients presented with unilateral disease (65%),
Pietermaritzburg, headache (48%), diplopia (30%) and blurred vision (30%). Third (65%) and sixth (57%) nerve
South Africa
palsies in isolation and combination (39%) were most common. Isolated fourth nerve palsy
2 Department of Neurology, did not occur. Tuberculosis (17%) was the most commonly identified disorder followed by
Universitas Hospital, high-grade B-cell lymphoma (13%), meningioma (13%), metastatic carcinoma (13%) and
University of the Free State, neurosyphilis (7%). In 22% of the patients, there was no confirmatory evidence for a
Bloemfontein, diagnosis. The patients were either treated empirically for tuberculosis or improved
South Africa
spontaneously when antiretroviral therapy was started. Cerebrospinal fluid was helpful in
Corresponding author: 4/13 (31%) of patients where it was not contraindicated. Only 3/23 (13%) of the patients had
Cait-lynn Wells, a biopsy of the cavernous sinus mass. The outcomes varied, and follow-up was lacking in
[email protected] the majority of patients.
Dates: Conclusion: In HIV-infected patients, histological confirmation of cavernous sinus pathology
Received: 25 Apr. 2018 is not readily available for various reasons. In resource-limited settings, one should first
Accepted: 05 Feb. 2019
Published: 20 Mar. 2019 actively search for extracranial evidence of tuberculosis, lymphoma, syphilis and primary
malignancy and manage appropriately. Only if such evidence is lacking should a referral for
How to cite this article: biopsy be considered.
Wells CD, Moodley AA.
HIV-associated cavernous
sinus disease. S Afr J HIV
Med. 2019;20(1), a862. Introduction
https://doi.org/10.4102/
sajhivmed.v20i1.862 The cavernous sinus, a venous structure at the base of the skull, contains important neurological
and vascular components that are susceptible to opportunistic infections, para-infectious disorders
Copyright: and neoplastic disorders in HIV-infected patients. The cavernous sinuses are two dura-enclosed
© 2019. The Authors.
1
Licensee: AOSIS. This work venous chambers connected by the circular sinus. The crossover of pathology between the two
is licensed under the sides is therefore not uncommon. Each cavernous sinus receives venous blood from the superior
Creative Commons and inferior ophthalmic veins and drains via the superior and inferior petrosal sinuses into
Attribution License. sigmoid sinuses bilaterally. The involvement of vital structures within the cavernous sinus
presents as a double-edged sword. They allow for early detection of cavernous sinus disease, but
their presence also heralds the presence of grave pathology.

Each cavernous sinus contains the carotid artery and the sixth cranial nerve lying within the sinus
(Figure 1). Sympathetic nerves that emerge from the carotid artery wall run along the sixth nerve for
a short distance and are then destined for the eye along the nasociliary branch of the fifth cranial
nerve. From rostral to caudal, the third, fourth and ophthalmic divisions of the fifth cranial nerve lie
within the lateral wall of the sinus and further back is a short encounter with the maxillary division
of the fifth nerve, which enters via the foramen rotundum en route to the Gasserian ganglion. The
cavernous sinus syndrome is defined as involvement of two or more of the third, fourth, fifth and
sixth cranial nerves or involvement of any amount of cranial nerves with neuro-imaging confirming
the presence of a cavernous sinus lesion. Clinically, various combinations of third nerve, fourth
nerve, sixth nerve, Horner syndrome, ophthalmic and maxillary division sensory loss are localised
to the cavernous sinus. The cavernous sinus is also secondarily affected by pathology in surrounding
structures, namely, the pituitary gland, the surrounding dura, the optic chiasm, the sphenoid sinus
Read online: and structures of the floor of the third ventricle. Lesions of the cavernous sinus that spread anteriorly
Read online:
Scan this QR to the orbital apex affect the optic nerve. 2
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code with your
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smart phone or
smart phone or
mobile device Causes of cavernous sinus pathology are protean. In a series of 151 patients, Keane et al.
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to read online. described the common causes for cavernous sinus lesions to be tumours (30%), trauma (24%) and
to read online.
http://www.sajhivmed.org.za 206 Open Access