Page 214 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 7 Original Research

TABLE 1: Case reports of patients infected with HIV and presenting with
cavernous sinus disease.
Temporal lobe Author (year) Relevant data Diagnosis
Gross et al. 12 35-year-old female Eosinophilic granuloma
Keane 3 3 patients B-cell lymphoma
CN III
Kleinschmidt-Demaster et al. 13 35-year-old, unilateral mass Leiomyosarcoma
Blumenthal et al. 14 43-year-old male, Leiomyosarcoma
Pituitary gland
CN IV CD4 23 cells/µL
Fernandez et al. 4 2 patients B-cell lymphoma
Internal CNVI Dhillon and Shah 15 25-year-old CD4 218 cells/µL B-cell lymphoma
caro d artery Junior et al. 16 51-year-old with bilateral Non-Hodgkin’s
V1 lesions lymphoma
Meltzer et al. 17 53-year-old with Nasopharyngeal
Sphenoid sinus nasopharyngeal mass carcinoma
V2 Humphrey et al. 18 47-year-old female, CD4 Aspergillosis
214 cells/µL
Sphenoid bone The literature in this population consists of mainly case
Caverrnous sinus reports (Table 1). Surprisingly, tuberculosis (TB) of the
FIGURE 1: The cavernous sinus showing cranial nerves III, IV, ophthalmic division cavernous sinus has not been described in HIV-infected
of V (V1) and maxillary division of V (V2) along the lateral wall of the sinus. The patients previously. In fact, TB of the cavernous sinus is an
VI cranial nerve lies free within the sinus. The sympathetic fibres, which enter 5
the cavernous sinus along the carotid artery, are not shown. uncommon disorder even in an immunocompetent patient.
The only infection reported is aspergillosis. Infection as an
self-limiting inflammation (23%), while carotid aneurysms, infrequent cause of cavernous sinus disease in HIV-infected
carotico-cavernous fistulae, infection and other causes patients is likely because of poor reporting or lack of
constituted the remaining 12%. The most common tumour in confirmatory evidence.
this series was nasopharyngeal carcinoma (22%), followed by
metastases (18%) and lymphoma (18%). The infectious We undertook a retrospective analysis to highlight the
aetiologies comprised one case of bacterial sphenoid sinusitis pathology and challenges encountered in the diagnosis and
and three cases of mucormycosis. In this series, there were management of HIV-infected patients with cavernous sinus
three patients who were HIV-infected, and all three were disease. Non-HIV-infected patients have similar challenges,
diagnosed with lymphoma. 3 but despite equity in the management of HIV-infected patients,
personal experience shows us that surgeons are more likely to
Fernandez et al. in their series of 126 patients found the most offer biopsies to non-HIV-infected patients for the fear of
common cause for cavernous sinus disease to be tumours (63%), negative outcomes post-surgery in HIV-infected patients.
vascular lesions (20%), inflammatory conditions such as Tolosa-
Hunt syndrome (13%) and miscellaneous causes (4%). Of the Twenty-three HIV-infected patients with cavernous sinus
miscellaneous causes, only two were because of infectious lesions as their main reason for referral were recruited. Their
aetiologies, namely, aspergillosis and thrombophlebitis from clinical, radiological and biochemical data were analysed.
Haemophilus influenzae infection. Pituitary adenoma and Problems encountered in their diagnosis and management
meningioma were the most frequent of the tumours at 36.25% will be highlighted.
and 31.25%, respectively. In this series, two HIV-infected
patients formed part of the cohort – both patients were Method
diagnosed with lymphoma. 4
All HIV-infected patients, from 2010 to 2016, referred to the
In the HIV population, one would predict that the disease neurology department of Grey’s Hospital, Pietermaritzburg,
spectrum would coincide with the immunocompromised state with non-traumatic cavernous sinus lesions as their main
of the patient, and opportunistic infections and HIV-associated presenting problem were included for analysis. The data
neoplastic disorders would be commonly encountered. search was done by selecting the keywords of cavernous
However, epidemiological data regarding cavernous sinus sinus and HIV in hospital records and patient summaries.
pathology in HIV-infected patients are lacking. The deep skull Clinical, biochemical and radiological data were obtained
base location of the cavernous sinus and the fact that most from hospital records. All data were captured on a
patients are severely immunosuppressed discourage invasive spreadsheet for descriptive statistics. Averages and
diagnostic procedures unless lesions are easily accessible via the standard deviations were obtained for continuous
paranasal sinuses. Histological confirmation is therefore scant. quantitative data and qualitative data were represented in
Often, the diagnosis is based on the presence of a systemic tables and graphs.
disease, or patients are treated empirically for the commonly
occurring diseases. The outcome therefore can be unpredictable Ethical consideration
and catastrophic at times.
Ethical approval (BE370/15) for a retrospective analysis was
There is no study that has specifically addressed obtained from the University of KwaZulu-Natal biomedical
cavernous sinus pathology in patients coinfected with HIV. research ethics committee.

http://www.sajhivmed.org.za 207 Open Access