Teaching Case

A 34-year-old female, without any risk factor for thrombosis, admitted for management of impaired consciousness.

The symptoms started 3 days before admission, with acute headache and vomiting, the evolution was marked by the onset of a disorder of consciousness. S. Typhi was isolated from the blood culture.

An unenhanced cerebral CT was requested, showing increased density of the cerebral scaffold and cerebellum tent with diffuse cerebral oedema.

We completed with a cerebral CT angiography, which came back in favour of an extensive thrombosis of the sagittal and lateral sinuses and of the right jugular vein.

Our patient had a Cerebral venous sinus thrombosis (CVST) complicating an infection with salmonella species; many etiologies can be responsible of this disease such of hypercoagulable state, and severe dehydration.

Typhoid fever is caused by the Gram-negative bacteria Salmonella (S), the presence of this bacteria in the systemic circulation could cause an activation of coagulation and a disseminated intravascular coagulopathy due to increased liberation of endotoxin or exotoxin of S.Typhi [1, 2].

CVST caused by typhoid fever is rare, and it has been sporadically reported in few cases [3, 4].

Computed tomography (CT) may show typical evidence of CSVT. Like described in our case, the unenhanced computed tomography shows a hyperdense appearance of the thrombosed sinus, representing acute thrombus or “cord sign” [5]. With contrast administration, a sinus filling defect on CT venography can confirm the diagnosis.

MRI is able to both visualise the clot, which appears acutely isointense on T1 and hypointense on T2 with subacute clot becoming hyperintense on T1, and absence of flow on MR venography.

Treatment with antibiotics and oral anticoagulation can lead to resolution of the symptoms and recanalization of the dural sinus [3].

Unfortunately, our patient had a delayed diagnosis. Intubated at her admission on a Glasgow scale 7 of 15, despite of the target antibiotic therapy and anticoagulation the evolution was cardiac arrest and death.

Although rare, systemic infection causing CVST should be considered in any patient with headache and fever, as early diagnosis and treatment can prevent severe consequences [3].

Written informed patient’s family consent for publication has been obtained.