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Case Presentation: An 18-year-old woman without previous medical history on oral contraceptives (OCP) presented to the emergency department with headache and vomiting. The headache first appeared 4 days ago; it was moderate in intensity, bitemporal and occipital, and resolved on its own. The headache reappeared 1 day before, waking the patient out of sleep. It was 10/10 in intensity and associated with nausea, vomiting, photophobia and severe fatigue. Outside hospital CT and MRI showed a right transverse sinus thrombosis extending into the right internal jugular vein. Lab abnormailities included platelets of 21 x 103/mm3, mild transaminitis, and CD4 count of 184/mm3. The patient was transferred to our hospital. While hospitalized, the patient revealed that she had a viral-like illness with cough, fever, and pharyngitis 1 week prior. She was started on heparin drip with close monitoring. The nadir of her platelets was 9 x 103/mm3. Hematology was consulted for possible immune thrombocytopenic purpura (ITP). She received 5 days of dexamethasone 40 mg and intravenous immunoglobulin (IVIG). Hypercoagulable workup was negative for Factor V Leiden, prothrombin G20210A mutations and antiphospholipid antibodies. Flow cytometry for paroxysmal nocturnal hemoglobinuria was negative. HIV testing and blood cultures were negative; serologies for parvovirus B19, cytomegalovirus, and mycoplasma were consistent with previous exposure, while serologies for Epstein-Barr virus (EBV) were consistent with acute infection. The patients platelets began to rise 9 days after admission, and she was transitioned to warfarin. At discharge 11 days after presentation her nausea had resolved and her headache had improved. A month later her platelets were normal, and she was asymptomatic. Discussion: Cerebral Venous Thrombosis (CVT) is uncommon, with an incidence of 3-13 cases per million. The disease is more common in women (~75% of cases) and in the young (78% occurred in patients <50 years old). The most common etiologies are antithrombin III, protein C, and protein S deficiencies; factor V Leiden; OCP; elevated homocysteine; and infection. The most common presenting symptom is headache (90%). The superior sagittal sinus is most often involved (62%). While somewhat controversial, major guidelines recommend treatment with anticoagulation, although the optimal duration is uncertain. At first glance our patient's CVT seems attributable to OCP use, but the presence of mild transaminitis, hepatomegaly, thrombocytopenia and decreased CD4 count with recent upper respiratory illness and fatigue raised the possibility this was due to EBV infection. There are rare case reports of EBV causing CVT. Conclusions: Cerebral venous thrombosis is an uncommon cause of headache. Although hypercoagulable states and oral contraceptives are the most commonly identified risk factors, infectious etiologies such as EBV are also in the differential.'


Society of Hospital Medicine: 2014 Abstracts Las Vegas, Nevada March 24-27, 2014.