Can a pimple be life-threatening?
In the field of clinical practice, every case presents a unique puzzle, offering lessons that enrich the knowledge and experience of medical professionals. Recently, I encountered a case that underscored the potential severity of seemingly innocuous issues.
A 17-year-old boy was presented to me with a seemingly trivial concern: a pimple on his nose. Little did he know that this seemingly minor irritation would cascade into a life-threatening condition known as CST (cavernous sinus thrombosis).
The young boy’s troubles began when he attempted to alleviate the discomfort of his pimple by squeezing it. Unfortunately, instead of relief, this action led to the rupture of the pimple beneath the skin. Soon after, his skin turned red and then progressed to a violaceous black hue—a sign of tissue damage caused by the spread of an infection. However, the most alarming development was yet to come. Shortly after the burst, he began experiencing a severe headache that proved resistant to conventional pain relievers.
As the intensity of his headache escalated, the boy’s condition deteriorated rapidly. He was rushed to the emergency room, but on route, he suffered a seizure—a frightening manifestation of his worsening state. This abrupt neurological event raised the stakes, underscoring the urgency of the situation.
Upon evaluation, it became apparent that the boy’s symptoms were indicative of a grave underlying condition: cavernous sinus thrombosis (CST). This rare but serious condition involves the formation of a blood clot within the cavernous sinus, a cavity located behind the eyes and at the base of the brain. The rupture of the pimple likely introduced bacteria into the bloodstream, leading to an infection known as facial cellulitis. This infection subsequently spread to the cavernous sinus, causing inflammation and the formation of a blood clot.
The most important lesson is to never pick or pop a pimple on your nose, the ‘dangerous triangle’ of your face. It could be hiding cavernous sinus thrombosis, a dangerous blood clot.
By definition, CST is a blood clot in the cavernous sinus. The jugular veins (major blood vessels that stretch from your head to your upper chest) carry blood through cavernous sinuses and away from the brain. In CST, the blood clot blocks the jugular veins that run through a hollow space underneath the brain and behind the sockets. These veins carry blood from the face and head back to the heart.
The clot is usually caused by an infection of the face or skull. When there is an infection, the jugular veins form a blood clot that prevents the infection from spreading further. However, it also restricts blood flow to the brain, which leads to inflammation, swelling, and pressure buildup due to blood accumulation in the sinus, which can lead to damage of the brain, eyes, and several nerves running between them, triggering a severe headache and other neurological symptoms experienced. Causes include sinus infections (sinusitis), boils, dental infections, and ear infections.
In up to 70% of cases, staphylococcus aureus bacteria cause the infection, but others, like HIV, herpes simplex, aspergillosis, etc., may lead to it as well. Other types of bacteria, some fungi, and viruses may also cause CST. There are also a few documented cases of cavernous sinus thrombosis related to COVID-19 infection. In some cases, CST is caused without an infection (trauma, surgery etc.), and other factors (immunosuppression, uncontrolled diabetes, steroid use, cancer, chemotherapy) also play a vital role in developing this disorder. Both adults and children are affected by CST. In nearly one in three cases of this disorder, it causes death. It is a severe condition that needs immediate medical attention.
Symptoms may include swelling, irritation, or inflammation around one or both the eyes, a severe headache often accompanied by tearing, inability to move the eyes, fatigue, high fever, vomiting, seizures, and altered mental status, which may range from confusion, numbness or pain around the face or eyes, and even to a coma.
As CST affects the eyes, the patient may also experience swelling and bulging of the eyes that starts from one eye and moves to the other as well, severe eye pain, red eyes, vision issues such as doubling or blurring, difficulty moving the eyes, and droopy eyelids.
Treatment and prognosis
Cavernous sinus thrombosis is a medical emergency that requires prompt intervention. The primary goal of treatment is to eradicate the underlying infection and prevent the clot from causing further damage. This typically involves a combination of intravenous antibiotics to combat the infection and anticoagulant therapy to prevent the clot from enlarging or propagating.
In severe cases, surgical drainage of the sinus may be necessary to relieve pressure and facilitate the resolution of symptoms. Additionally, supportive measures such as pain management and seizure control are vital to ensure the patient’s comfort and stability.
Despite advances in medical care, CST remains a potentially life-threatening condition. As many as 50% of survivors might have sequelae, most commonly third or sixth nerve paralysis or paresis (weakness or partial paralysis). Other complications can include sepsis, meningitis, subdural emphysema, brain abscess, blindness, panhypopituitarism, intracranial hypertension, infectious arteritis or mycotic aneurysm of the internal carotid artery, vasospasm, septic emboli, a stroke from carotid artery narrowing, brain hemorrhagic infarction, coma, and death. Mortality rates are as high as eight to 13% now compared to 80% before the era of antibiotics. These complications can occur if the condition is not promptly diagnosed and treated. However, with timely and appropriate management, many patients can achieve a full recovery.
The case of the 17-year-old-boy serves as a poignant reminder that what may initially seem like a trivial concern—a pimple—can quickly escalate into a life-threatening emergency. The most important lesson is to never pick or pop a pimple on your nose, the “dangerous triangle” of your face.
“If you pick your face with dirty fingers, dirty nails or have dirty skin, you run the risk of causing a skin infection,” says Dr. Joshua Zeichner, director of cosmetic and clinical research at the Department of Dermatology at Mount Sinai in New York. “In the central face, this is particularly risky because the blood in this area drains into a large collection of veins known as the cavernous sinus, which has a direct connection to the brain. So theoretically, bacteria in the bloodstream could spread to the brain, causing a severe, systemic infection.”
As healthcare professionals, it is imperative that we remain vigilant and responsive to the evolving needs of our patients, recognizing that even the smallest symptoms can herald significant underlying pathology. Through continued education, collaboration, and dedication to excellence in care, we can strive to ensure the best possible outcomes for those entrusted to our care.
