A 13-year-old male with ptosis.

A 13-year-old, previously healthy African-American male presented with a 12-hour history of double vision and inability to open his left eye. This was associated with 8 days of moderate to severe left temporal headache that was made worse by sunlight, television, and noise. He had also experienced intermittent nausea, vomiting, and fever over the prior 10 days. During the initial course of his illness, he took ibuprofen because he was diagnosed with possible migraine at an outside hospital. On clinical presentation, he was febrile with a temperature of 101.4°F. On cardiac examination, there was a grade 2/6 systolic murmur at the left lower sternal border. Ophthalmologic examination showed left eye ptosis (see Figure 1), mydriasis, and absent consensual/direct light reflex. Extraocular movements were limited in lateral, medial, and downward directions. Visual acuity was 20/30 in the right eye and 20/50 in the left eye. There were no dental caries and no evidence of odontogenic infection. The rest of the physical examination was unremarkable. Laboratory tests revealed a white blood cell count of 24.3 x 109/L with a neutrophilia of 80.6%. C-reactive protein level was elevated at 18.09 mg/L. Sodium was 127 mEq/L and chloride was 88 mEq/L. Liver function, urine analysis, and HIV tests were normal. Lumbar puncture showed clear cerebrospinal fluid with a high white blood cell count 70 cells/mcL with neutrophils 79%, glucose 65 mg/dL, and protein 51 mg/dL. Antinuclear antibody, antineutrophil cytoplasmic antibody, complement component 3, complement component 4, and immunoglobulin panel, which were performed to rule out a possible vasculitis or immunodeficiency were normal. Echocardiogram showed no evidence of any intracardiac vegetations or valvular abnormalities. Magnetic resonance imaging (MRI) showed a contrast-enhancing soft tissue lesion involving the left cavernous sinus. Minimal mucoperiosteal thickening involving bilateral ethmoidal and left sphenoid sinus was also seen. MR angiography (MRA) revealed the diagnosis, and subsequent blood culture revealed the causative organism.