Cerebral Venous Sinus Thrombosis Following Varicella Infection: A Case Report.

Abstract

A 38-year-old man presented to the emergency department with a severe frontal headache, which began three days prior without visual, speech, or balance disturbances. His past medical history was unremarkable, apart from raised cholesterol. He confirmed a recent primary Varicella-zoster virus infection (chicken pox) two weeks prior. Clinical examination revealed crusted varicella lesions on the arms, trunk, and thighs. The neurological examination revealed no deficits, neck rigidity, or abnormal gait. Routine blood investigations were unremarkable. Autoantibody screen and HIV serology were negative. CT head non-contrast showed evidence of hyperdense bilateral transverse sinus thrombosis. To confirm the findings, a CT venogram showed extensive and occlusive left transverse and sigmoid sinus thrombosis with further extension into the left internal jugular vein. The stroke team advised an MRI of the head, which reported no acute infarction, and magnetic resonance venography (MRV), which further confirmed the occlusion in the left transverse sinus, sigmoid sinus, and jugular vein. Hematology was involved and advised to start warfarin and bridging therapy with enoxaparin. His migraines experienced a substantial improvement within 48 hours of commencing treatment. He was subsequently discharged with outpatient follow-up. He continued on warfarin with a therapeutic international normalized ratio (INR) range of two to three for one year. A thrombophilia screen, JAK2, and lupus anticoagulant were checked by hematology as part of outpatient investigations. During the first six months, he experienced mild intermittent headaches; however, for the following six months, his symptoms ultimately resolved. Following a clinic evaluation one year later, his warfarin was discontinued.