Cerebral venous sinus thrombosis secondary to nasopharyngeal abscess with Klebsiella pneumoniae infection in an elderly patient with multiple comorbidities: a case report

Cerebral venous sinus thrombosis secondary to nasopharyngeal abscess with Klebsiella pneumoniae infection in an elderly patient with multiple comorbidities: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Cerebral venous sinus thrombosis secondary to nasopharyngeal abscess with Klebsiella pneumoniae infection in an elderly patient with multiple comorbidities: a case report Yujun Wu, Daojie Huang, Liyan Gu, Yongqiu Zhang, Jie Wei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8653905/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Cerebral venous sinus thrombosis (CVST) is a rare but severe cerebrovascular disorder. While often associated with hypercoagulable states, infections, particularly those involving the head and neck region, can be a significant predisposing factor. Klebsiella pneumoniae is a known pathogen causing invasive syndromes, including liver abscesses and metastatic infections, but its association with nasopharyngeal abscess leading to CVST and cavernous sinus syndrome is exceptionally rare, especially in elderly patients with complex medical backgrounds. Case presentation We report the case of a 77-year-old Chinese male with a history of hypertension and type 2 diabetes (poorly controlled), who presented with a 27-day history of paroxysmal headache and 10 days of progressive lethargy and gait instability. He subsequently developed bilateral eyelid ptosis, eyelid edema, chemosis, and ophthalmoplegia. Imaging studies identified a nasopharyngeal abscess with associated cavernous sinus thrombosis. Microbiological analysis of nasopharyngeal abscess fluid and blood targeted next-generation sequencing (tNGS) confirmed Klebsiella pneumoniae as the causative organism. The patient was managed with a multidisciplinary approach involving prolonged intravenous antibiotic therapy (Initially, meropenem and teicoplanin were administered; subsequently, the antibiotics were switched to levofloxacin and piperacillin-tazobactam based on the results of antimicrobial susceptibility testing ), anticoagulation, intensive glycemic and blood pressure control, and nutritional support. After a 22-day hospitalization, his symptoms significantly improved, inflammatory markers normalized, and he was discharged on a 4–6 week course of oral antibiotics (levofloxacin and piperacillin-tazobactam formulation). Conclusion This case highlights a rare life-threatening complication of Klebsiella pneumoniae-induced nasopharyngeal abscess progressing to septic cavernous sinus thrombosis and cavernous sinus syndrome in an elderly immunocompromised patient with diabetes. It underscores the importance of considering invasive Klebsiella pneumoniae infection in the differential diagnosis of cranial neuropathies and CVST, particularly in patients with poor glycemic control. Early recognition, aggressive antimicrobial therapy, and anticoagulation are crucial for favorable outcomes. Cerebral venous sinus thrombosis Cavernous sinus syndrome Klebsiella pneumoniae Nasopharyngeal abscess Diabetes mellitus case report༛ Figures Figure 1 Figure 2 Figure 3 Background Cerebral venous sinus thrombosis (CVST) is an uncommon form of stroke, accounting for 0.5-1% of all strokes, with an estimated annual incidence of 1.32–1.57 per 100,000 adults [ 1 , 2 ]. Risk factors are diverse, including prothrombotic conditions, pregnancy, oral contraceptives, and local or systemic infections [ 3 ]. Infectious causes, particularly from contiguous foci in the head (e.g., sinusitis, otitis, mastoiditis, facial infections), can lead to septic thrombophlebitis of the dural sinuses [ 4 ].Klebsiella pneumoniae, especially hypervirulent strains, is notorious for causing community-acquired pyogenic infections beyond the urinary and respiratory tracts, most classically primary liver abscesses [ 5 ]. A distinct "invasive syndrome" associated with Klebsiella pneumoniae liver abscess includes metastatic complications such as endophthalmitis, meningitis, and other distant septic foci [ 6 , 7 ]. However, direct extension from a nasopharyngeal abscess to cause cavernous sinus thrombosis and syndrome is a rarely documented manifestation. The cavernous sinus is a critical structure containing the internal carotid artery and cranial nerves III (oculomotor nerve), IV (trochlear nerve), V₁ (ophthalmic division of the trigeminal nerve), and VI (abducens nerve). Infection or thrombosis in this region leads to cavernous sinus syndrome, characterized by ophthalmoplegia, ptosis, proptosis, and facial sensory deficits [ 8 ]. Its development secondary to a nasopharyngeal abscess represents a severe, potentially fatal complication requiring urgent intervention. We present a complex case of an elderly diabetic male who developed CVST and cavernous sinus syndrome secondary to a Klebsiella pneumoniae nasopharyngeal abscess. This case illustrates the diagnostic challenges and the necessity for a comprehensive, multidisciplinary management strategy in patients with significant comorbidities. Case Presentation A 77-year-old Chinese male was admitted to the neurology department on December 3, 2025, with a 27-day history of paroxysmal, throbbing headache localized to the bilateral temporal regions and jaw (worsening between 2–5 AM) and 10 days of progressive lethargy and unsteady gait requiring assistance. His medical history was significant for hypertension and type 2 diabetes mellitus (over 10 years' duration) with suboptimal glycemic control. He had a remote smoking history (quit > 10 years prior). Prior to admission, he was evaluated at another hospital. A head CT (November 2025) showed hypodensities around the lateral ventricles and semioval centers, suggestive of leukoaraiosis. Subsequent brain MRI/MRA/MRV (November 24, 2025) revealed multiple lacunar infarcts, Fazekas grade 3 white matter hyperintensities, and left posterior communicating artery agenesis (presumed developmental variant). He was diagnosed with "cerebrovascular disease convalescence" and treated with clopidogrel, hypoglycemic agents (insulin glargine, acarbose, metformin), and antihypertensives (valsartan, amlodipine, nimodipine), without clinical improvement. He subsequently developed bilateral eyelid ptosis, eyelid edema, chemosis, and ophthalmoplegia (Fig. 3A and B). On admission, vital signs were stable (temperature 37.2°C, heart rate 78 beats/min, blood pressure 145/90 mmHg, respiratory rate 18 breaths/min, oxygen saturation 96% on room air). Neurological assessment revealed apathy, sparse speech, bilateral eyelid edema, chemosis, ptosis, and restricted upward, downward, and adduction eye movements. Muscle strength was graded 4/5 in all extremities, with absent tendon reflexes. Laboratory tests on admission showed leukocytosis (white blood cell count [WBC] 12.17×10⁹/L, neutrophils 85.2%), markedly elevated C-reactive protein (CRP > 200 mg/L), hyperglycemia (random glucose 12.97 mmol/L), hypoalbuminemia (25.9 g/L), and thrombocytopenia (platelets 46×10⁹/L). Coagulation studies revealed elevated D-dimer (1.836 µg/mL) and fibrinogen (6.8 g/L). Contrast-enhanced MRI of the head and neck (December 11, 2025; Fig. 1) revealed a cystic mass with rim enhancement in the nasopharynx (effacing the pharyngeal recesses), a small filling defect in the cavernous sinus (suggestive of thrombosis), abnormal signal in the clivus, and mild meningeal enhancement — consistent with a nasopharyngeal abscess and associated complications. Initial magnetic resonance venography (MRV) was reported as normal, but clinical and imaging context strongly supported septic cavernous sinus thrombosis. Lumbar puncture performed on December 4 yielded clear cerebrospinal fluid (CSF) with an opening pressure of 120 mmH₂O. CSF analysis showed normal cell count (WBC 3×10⁶/L, red blood cell count 5×10⁶/L) but elevated protein (0.85 g/L); glucose and chloride levels were within normal ranges. CSF tNGS detected Klebsiella pneumoniae in the gray zone (41 sequences, low-level detection), while peripheral blood tNGS identified Klebsiella pneumoniae with high confidence (4165 sequences, concentration 2.18×10⁴ copies/mL, high signal intensity) and multiple virulence genes (allB, clbD, ybtE). The raw tNGS data of CSF and blood have been deposited in the SRA database (BioProject: PRJNA1403655) for public access. Culture of nasopharyngeal abscess fluid also grew Klebsiella pneumoniae, which was sensitive to carbapenems, quinolones, and piperacillin-tazobactam. A final diagnosis was established: 1) Nasopharyngeal abscess with cavernous sinus syndrome and cavernous sinus thrombosis (septic); 2) Community-acquired pneumonia (mild); 3) Hypertension stage 3 (very high risk); 4) Type 2 Diabetes Mellitus (poorly controlled); 5) Hypoalbuminemia; 6) Thrombocytopenia; 7) Mild anemia. Management and Outcome The patient was initially placed on critical care monitoring. Empirical broad-spectrum intravenous antibiotic therapy was initiated with meropenem (1 g q8h) and teicoplanin (400 mg q24h). Based on culture sensitivity and clinical response, antibiotics were switched to intravenous levofloxacin (0.5 g q24h) and piperacillin-tazobactam (4.5 g q8h) on hospital day 7. Therapeutic anticoagulation with enoxaparin (4000 AXaIU q12h) was initiated on hospital day 3 (after confirming no active bleeding and improving thrombocytopenia). Intensive comorbidity management included subcutaneous insulin (basal-bolus regimen) for glycemic control, optimized antihypertensive therapy (valsartan + amlodipine), intravenous albumin supplementation (20 g q48h), and enteral nutritional support. His clinical course was complicated by persistent low-grade fever (37.5–38.0°C) and elevated inflammatory markers in the first week. Over three weeks of treatment, symptoms gradually improved (Fig. 3 CandD): headache resolved, ptosis and ophthalmoplegia recovered, eyelid edema and chemosis subsided, and inflammatory markers normalized (CRP decreased to 3.24 mg/L; PCT to 0.21 ng/mL). Hypoalbuminemia (35.2 g/L) and thrombocytopenia (156×10⁹/L) were corrected. A follow-up chest CT (December 10, 2025) showed resolution of mild pulmonary inflammation. The patient was discharged on December 25, 2025, in stable condition with a plan for 4–6 weeks of oral antibiotic therapy (levofloxacin 0.5 g q24h and oral piperacillin-tazobactam formulation 3.375 g q8h) and close outpatient follow-up (neurology, infectious diseases, and endocrinology clinics). Follow-up At 1-month follow-up after discharge, clinical assessment revealed complete resolution of headache, ptosis, and ophthalmoplegia. Bilateral eyelid edema and chemosis had largely subsided, with restored gait stability (modified Rankin Scale score of 0). Inflammatory markers remained within the normal range. A follow-up non-contrast brain magnetic resonance imaging (MRI) was performed on January 24, 2026. Diffusion-weighted imaging (DWI) showed nearly resolved restricted diffusion in the previously involved area (Fig. 2A), and T1-weighted imaging confirmed abscess reduction and inflammatory resolution (Fig. 2B). The patient completed the planned 6-week course of oral antibiotic therapy without reporting any adverse events. Discussion and Conclusion This case describes a rare sequential complication: Klebsiella pneumoniae-induced nasopharyngeal abscess progressing to cavernous sinus syndrome and septic CVST. The patient’s poorly controlled diabetes mellitus was a critical predisposing factor, as hyperglycemia impairs immune cell function and facilitates invasive bacterial infection [ 9 ].Diagnostic challenges arose from non-specific initial symptoms (headache, gait instability) that mimicked cerebrovascular disease. The key diagnostic turning point was the development of bilateral ophthalmoplegia, ptosis, eyelid edema, and chemosis — classic manifestations of cavernous sinus pathology. Contrast-enhanced MRI was pivotal for identifying the nasopharyngeal abscess and cavernous sinus thrombosis, while tNGS and abscess culture confirmed Klebsiella pneumoniae as the etiologic agent. Notably, initial MRV was normal, which highlights that standard MRV may not always detect early septic thrombosis; clinical correlation with imaging and microbiology is essential.Management required a three-pronged approach: 1) Infection eradication with long-course, pathogen-targeted antibiotics (consistent with guidelines for severe Klebsiella pneumoniae infections [ 6 ]); 2) Anticoagulation for CVST (balancing thrombus propagation risk against bleeding risk, which resolved with treatment); 3) Comprehensive supportive care (glycemic/hypertensive control, nutritional support) — critical for elderly frail patients. Surgical drainage of the nasopharynx abscess was not performed due to patient/family preference and significant clinical improvement with medical therapy alone. This case adds to the limited literature on Klebsiella pneumoniae-induced nasopharyngeal abscess complicated by CVST. It underscores that invasive Klebsiella pneumoniae should be considered in diabetic patients presenting with cranial neuropathies and systemic infection. Early contrast-enhanced MRI, tNGS (for rapid pathogen identification), and prompt initiation of antimicrobial therapy plus anticoagulation are key to preventing catastrophic neurological sequelae. Study Limitations This is a single-center retrospective case report with inherent selection bias and limited generalizability. Lack of long-term follow-up beyond 1 month precludes assessment of long-term neurological prognosis and recurrence risk and recurrence risk. Bacterial molecular characterization (e.g., virulence gene expression) and host genetic analysis were not performed, limiting insight into pathophysiological mechanisms. Conservative management of the abscess and anticoagulation in the setting of thrombocytopenia lack uniform guidelines, requiring validation by prospective multicenter studies. Abbreviations CVST Cerebral Venous Sinus Thrombosis tNGS targeted Next-Generation Sequencing MRI Magnetic Resonance Imaging MRV Magnetic Resonance Venography CT Computed Tomography CSF Cerebrospinal Fluid CRP C-Reactive Protein PCT Procalcitonin WBC White Blood Cell Count Declarations Acknowledgements We thank the patient and his family for their informed consent and cooperation. We also acknowledge the support of the clinical laboratory and radiology departments of the Chinese People's Liberation Army Navy No. 905 Hospital. Author Contributions Yujun Wu: Data collection, patient follow-up, manuscript writing (original draft), and revision. Daojie Huang: Medical history collection, patient data management, clinical observation and outcome assessment, patient photograph acquisition, and manuscript revision. Yongqiu Zhang: Interpretation of cranial MRI findings, provision of imaging professional opinions, and manuscript review. Liyan Gu: Research framework construction, project development, and manuscript proofreading. Jie Wei: Study design, research framework construction, supervision of data collection, and manuscript finalization. All authors have read and approved the final manuscript. Financial support and sponsorship This work was supported by the Huashan Hospital Postdoctoral Training Program; the Naval Medical University "Zhuyuan" Talent Program (Grant No. 2022KYZ09); and the "Deep Blue Talent" Huashan Backbone Talent Project of the No. 905th Hospital of PLA Navy. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. The raw targeted next-generation sequencing (tNGS) data of cerebrospinal fluid and blood have been deposited in the NCBI Sequence Read Archive (SRA) database under the BioProject accession number PRJNA1403655 Ethics Statement This study was approved by the Ethics Committee of the Chinese People's Liberation Army Navy No. 905 Hospital (Approval No.2026- Ethical Opinion-LW07 ). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. All procedures were conducted in accordance with the Declaration of Helsinki. Clinical trial number Not applicable. Consent for publication Written informed consent for publication was obtained from the patient. Conflict of Interest Statement All authors declare no potential conflicts of interest, including financial, professional, or personal relationships related to the subject matter or materials discussed in the manuscript. References Coutinho JM, Zuurbier SM, Aramideh M, Stam J. The incidence of cerebral venous thrombosis: a cross-sectional study. Stroke. 2012;43(12):3375–7. Devasagayam S, Wyatt B, Leyden J, Kleinig T. Cerebral venous sinus thrombosis incidence is higher than previously thought: a retrospective population-based study. Stroke. 2016;47(9):2180–2. Saposnik G, Barinagarrementeria F, Brown RD Jr, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(4):1158–92. Ferro JM, Bousser MG, Canhão P, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis — endorsed by the European Academy of Neurology. Eur J Neurol. 2017;24(10):1203–13. https://doi.org/10.1111/ene.13381 . Siu LK, Yeh KM, Lin JC, Fung CP, Chang FY. Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet Infect Dis. 2012;12(11):881–7. Fang CT, Lai SY, Yi WC, et al. Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis. 2007;45(3):284–93. Sun R, Zhang H, Xu Y, et al. Klebsiella pneumoniae-related invasive liver abscess syndrome complicated by purulent meningitis: a review of the literature and description of three cases. BMC Infect Dis. 2021;21:15. Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to sinusitis: are anticoagulants indicated? A review of the literature. J Laryngol Otol. 2002;116(9):667–76. Zhang Q, Wang P, Shen M, Shan C. Clinical characteristics and risk factors for Klebsiella pneumoniae bloodstream infection in 152 immunocompetent patients. J Infect Developing Ctries. 2024;18(2):219–26. 10.3855/jidc.18204 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Mar, 2026 Reviews received at journal 30 Mar, 2026 Reviewers agreed at journal 23 Mar, 2026 Reviews received at journal 15 Feb, 2026 Reviews received at journal 11 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviewers agreed at journal 06 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Editor invited by journal 22 Jan, 2026 Editor assigned by journal 21 Jan, 2026 Submission checks completed at journal 21 Jan, 2026 First submitted to journal 20 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8653905","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":588526476,"identity":"a3d6e01a-565a-443d-a7c7-e5dd8c1001d5","order_by":0,"name":"Yujun Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYLACCQYGOTZm9oMPEipsiNdizM/Ok2zw4Ewa8RYlzuxnMJN82HaIsFKDGzlmEpZtdxg3HGZIq0hgO8DA396dQFiLZNszZoPDjMduJPDcYZA4c3YDXi1mEC2H2QyAttxIkHjGYCCRS5wWHqAWs4IEIEm0FgnJZgYzhoQEIrTYn3lWbCFx7rABPzNPskTCgTQegn6RbE/eeFui7HB9G//xgx9//rOR42/vxa+FgYHDgFkCictDQDkIsD9g/ECEslEwCkbBKBjBAACmQUlanL7i3QAAAABJRU5ErkJggg==","orcid":"","institution":"Chinese People's Liberation Army Navy No. 905 Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yujun","middleName":"","lastName":"Wu","suffix":""},{"id":588526477,"identity":"ef68a074-1b59-45b9-a1f5-6f85fabc5b97","order_by":1,"name":"Daojie Huang","email":"","orcid":"","institution":"Chinese People's Liberation Army Navy No. 905 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Daojie","middleName":"","lastName":"Huang","suffix":""},{"id":588526478,"identity":"be743169-d005-42cd-a836-cd309191275b","order_by":2,"name":"Liyan Gu","email":"","orcid":"","institution":"Chinese People's Liberation Army Navy No. 905 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Liyan","middleName":"","lastName":"Gu","suffix":""},{"id":588526479,"identity":"57d471bd-574c-4625-bedf-0a35b2170390","order_by":3,"name":"Yongqiu Zhang","email":"","orcid":"","institution":"Chinese People's Liberation Army Navy No. 905 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yongqiu","middleName":"","lastName":"Zhang","suffix":""},{"id":588526480,"identity":"6128cb56-50d8-419d-888f-373c0e49602a","order_by":4,"name":"Jie Wei","email":"","orcid":"","institution":"Chinese People's Liberation Army Navy No. 905 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Wei","suffix":""}],"badges":[],"createdAt":"2026-01-21 01:24:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8653905/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8653905/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102428766,"identity":"b7cbc37d-d7b7-4123-be60-6a53a34cc10c","added_by":"auto","created_at":"2026-02-11 14:58:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":778009,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNasopharyngeal Abscess Complicated with Right Cavernous Sinus Thrombosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e• Panel A: Axial Susceptibility-Weighted Imaging (SWI) showing hyperintensity in the nasopharyngeal abscess area(arrow);\u003c/p\u003e\n\u003cp\u003e• Panel B: Axial T1-weighted contrast-enhanced MRI demonstrating the enhancing abscess wall(arrow);\u003c/p\u003e\n\u003cp\u003e• Panel C: Sagittal T1-weighted contrast-enhanced MRI revealing mild enhancement of the clival meninges(arrow);\u003c/p\u003e\n\u003cp\u003e• Panel D: Coronal T1-weighted contrast-enhanced MRI showing a filling defect in the right cavernous sinus (arrow), consistent with thrombosis.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8653905/v1/2cc1f28c8433204abfe53f62.jpg"},{"id":102428767,"identity":"7d06450d-1387-40be-9041-a4eba2a3c7d0","added_by":"auto","created_at":"2026-02-11 14:58:26","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":865243,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFollow-up MRI Findings at 1 Month After Discharge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e• Panel A: Axial Diffusion-Weighted Imaging (DWI) showing mild restricted diffusion in the nasopharyngeal and cavernous sinus regions(arrow)；\u003c/p\u003e\n\u003cp\u003e• Panel B: Axial non-contrast MRI showed a significant reduction in the extent of the abscess compared with the prior examination(arrow).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8653905/v1/99d71da81e66e7d68af7df7a.jpg"},{"id":102428768,"identity":"a65eddf0-9ef1-4c2a-b5d9-2951d07a2b84","added_by":"auto","created_at":"2026-02-11 14:58:27","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":96849,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClinical Course of Ocular Manifestations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e• Panels A and B: Bilateral chemosis, eyelid edema, and ocular erythema on admission;\u003c/p\u003e\n\u003cp\u003e• Panel C: Regression of ocular erythema and partial resolution of chemosis on hospital day 14;\u003c/p\u003e\n\u003cp\u003e• Panel D: Complete resolution of chemosis and near-complete resolution of eyelid edema/ocular erythema before discharge.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8653905/v1/969055b1c71e701e27ec5a3f.jpg"},{"id":102962156,"identity":"b5ab8b3e-a116-486b-a45d-fb7f542fc434","added_by":"auto","created_at":"2026-02-19 04:04:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2237998,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8653905/v1/3c93641a-ba0f-4061-8719-d622b6953462.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cerebral venous sinus thrombosis secondary to nasopharyngeal abscess with Klebsiella pneumoniae infection in an elderly patient with multiple comorbidities: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eCerebral venous sinus thrombosis (CVST) is an uncommon form of stroke, accounting for 0.5-1% of all strokes, with an estimated annual incidence of 1.32\u0026ndash;1.57 per 100,000 adults [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Risk factors are diverse, including prothrombotic conditions, pregnancy, oral contraceptives, and local or systemic infections [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Infectious causes, particularly from contiguous foci in the head (e.g., sinusitis, otitis, mastoiditis, facial infections), can lead to septic thrombophlebitis of the dural sinuses [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].Klebsiella pneumoniae, especially hypervirulent strains, is notorious for causing community-acquired pyogenic infections beyond the urinary and respiratory tracts, most classically primary liver abscesses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A distinct \"invasive syndrome\" associated with Klebsiella pneumoniae liver abscess includes metastatic complications such as endophthalmitis, meningitis, and other distant septic foci [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, direct extension from a nasopharyngeal abscess to cause cavernous sinus thrombosis and syndrome is a rarely documented manifestation.\u003c/p\u003e \u003cp\u003eThe cavernous sinus is a critical structure containing the internal carotid artery and cranial nerves III (oculomotor nerve), IV (trochlear nerve), V₁ (ophthalmic division of the trigeminal nerve), and VI (abducens nerve). Infection or thrombosis in this region leads to cavernous sinus syndrome, characterized by ophthalmoplegia, ptosis, proptosis, and facial sensory deficits [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Its development secondary to a nasopharyngeal abscess represents a severe, potentially fatal complication requiring urgent intervention.\u003c/p\u003e \u003cp\u003eWe present a complex case of an elderly diabetic male who developed CVST and cavernous sinus syndrome secondary to a Klebsiella pneumoniae nasopharyngeal abscess. This case illustrates the diagnostic challenges and the necessity for a comprehensive, multidisciplinary management strategy in patients with significant comorbidities.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 77-year-old Chinese male was admitted to the neurology department on December 3, 2025, with a 27-day history of paroxysmal, throbbing headache localized to the bilateral temporal regions and jaw (worsening between 2\u0026ndash;5 AM) and 10 days of progressive lethargy and unsteady gait requiring assistance. His medical history was significant for hypertension and type 2 diabetes mellitus (over 10 years' duration) with suboptimal glycemic control. He had a remote smoking history (quit\u0026thinsp;\u0026gt;\u0026thinsp;10 years prior).\u003c/p\u003e \u003cp\u003ePrior to admission, he was evaluated at another hospital. A head CT (November 2025) showed hypodensities around the lateral ventricles and semioval centers, suggestive of leukoaraiosis. Subsequent brain MRI/MRA/MRV (November 24, 2025) revealed multiple lacunar infarcts, Fazekas grade 3 white matter hyperintensities, and left posterior communicating artery agenesis (presumed developmental variant). He was diagnosed with \"cerebrovascular disease convalescence\" and treated with clopidogrel, hypoglycemic agents (insulin glargine, acarbose, metformin), and antihypertensives (valsartan, amlodipine, nimodipine), without clinical improvement. He subsequently developed bilateral eyelid ptosis, eyelid edema, chemosis, and ophthalmoplegia (Fig.\u0026nbsp;3A and B).\u003c/p\u003e \u003cp\u003eOn admission, vital signs were stable (temperature 37.2\u0026deg;C, heart rate 78 beats/min, blood pressure 145/90 mmHg, respiratory rate 18 breaths/min, oxygen saturation 96% on room air). Neurological assessment revealed apathy, sparse speech, bilateral eyelid edema, chemosis, ptosis, and restricted upward, downward, and adduction eye movements. Muscle strength was graded 4/5 in all extremities, with absent tendon reflexes.\u003c/p\u003e \u003cp\u003eLaboratory tests on admission showed leukocytosis (white blood cell count [WBC] 12.17\u0026times;10⁹/L, neutrophils 85.2%), markedly elevated C-reactive protein (CRP\u0026thinsp;\u0026gt;\u0026thinsp;200 mg/L), hyperglycemia (random glucose 12.97 mmol/L), hypoalbuminemia (25.9 g/L), and thrombocytopenia (platelets 46\u0026times;10⁹/L). Coagulation studies revealed elevated D-dimer (1.836 \u0026micro;g/mL) and fibrinogen (6.8 g/L).\u003c/p\u003e \u003cp\u003eContrast-enhanced MRI of the head and neck (December 11, 2025; Fig.\u0026nbsp;1) revealed a cystic mass with rim enhancement in the nasopharynx (effacing the pharyngeal recesses), a small filling defect in the cavernous sinus (suggestive of thrombosis), abnormal signal in the clivus, and mild meningeal enhancement \u0026mdash; consistent with a nasopharyngeal abscess and associated complications. Initial magnetic resonance venography (MRV) was reported as normal, but clinical and imaging context strongly supported septic cavernous sinus thrombosis. Lumbar puncture performed on December 4 yielded clear cerebrospinal fluid (CSF) with an opening pressure of 120 mmH₂O. CSF analysis showed normal cell count (WBC 3\u0026times;10⁶/L, red blood cell count 5\u0026times;10⁶/L) but elevated protein (0.85 g/L); glucose and chloride levels were within normal ranges. CSF tNGS detected Klebsiella pneumoniae in the gray zone (41 sequences, low-level detection), while peripheral blood tNGS identified Klebsiella pneumoniae with high confidence (4165 sequences, concentration 2.18\u0026times;10⁴ copies/mL, high signal intensity) and multiple virulence genes (allB, clbD, ybtE). The raw tNGS data of CSF and blood have been deposited in the SRA database (BioProject: PRJNA1403655) for public access. Culture of nasopharyngeal abscess fluid also grew Klebsiella pneumoniae, which was sensitive to carbapenems, quinolones, and piperacillin-tazobactam.\u003c/p\u003e \u003cp\u003eA final diagnosis was established: 1) Nasopharyngeal abscess with cavernous sinus syndrome and cavernous sinus thrombosis (septic); 2) Community-acquired pneumonia (mild); 3) Hypertension stage 3 (very high risk); 4) Type 2 Diabetes Mellitus (poorly controlled); 5) Hypoalbuminemia; 6) Thrombocytopenia; 7) Mild anemia.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eManagement and Outcome\u003c/h2\u003e \u003cp\u003eThe patient was initially placed on critical care monitoring. Empirical broad-spectrum intravenous antibiotic therapy was initiated with meropenem (1 g q8h) and teicoplanin (400 mg q24h). Based on culture sensitivity and clinical response, antibiotics were switched to intravenous levofloxacin (0.5 g q24h) and piperacillin-tazobactam (4.5 g q8h) on hospital day 7. Therapeutic anticoagulation with enoxaparin (4000 AXaIU q12h) was initiated on hospital day 3 (after confirming no active bleeding and improving thrombocytopenia). Intensive comorbidity management included subcutaneous insulin (basal-bolus regimen) for glycemic control, optimized antihypertensive therapy (valsartan\u0026thinsp;+\u0026thinsp;amlodipine), intravenous albumin supplementation (20 g q48h), and enteral nutritional support.\u003c/p\u003e \u003cp\u003eHis clinical course was complicated by persistent low-grade fever (37.5\u0026ndash;38.0\u0026deg;C) and elevated inflammatory markers in the first week. Over three weeks of treatment, symptoms gradually improved (Fig.\u0026nbsp;3 CandD): headache resolved, ptosis and ophthalmoplegia recovered, eyelid edema and chemosis subsided, and inflammatory markers normalized (CRP decreased to 3.24 mg/L; PCT to 0.21 ng/mL). Hypoalbuminemia (35.2 g/L) and thrombocytopenia (156\u0026times;10⁹/L) were corrected. A follow-up chest CT (December 10, 2025) showed resolution of mild pulmonary inflammation. The patient was discharged on December 25, 2025, in stable condition with a plan for 4\u0026ndash;6 weeks of oral antibiotic therapy (levofloxacin 0.5 g q24h and oral piperacillin-tazobactam formulation 3.375 g q8h) and close outpatient follow-up (neurology, infectious diseases, and endocrinology clinics).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFollow-up\u003c/h3\u003e\n\u003cp\u003eAt 1-month follow-up after discharge, clinical assessment revealed complete resolution of headache, ptosis, and ophthalmoplegia. Bilateral eyelid edema and chemosis had largely subsided, with restored gait stability (modified Rankin Scale score of 0). Inflammatory markers remained within the normal range. A follow-up non-contrast brain magnetic resonance imaging (MRI) was performed on January 24, 2026. Diffusion-weighted imaging (DWI) showed nearly resolved restricted diffusion in the previously involved area (Fig.\u0026nbsp;2A), and T1-weighted imaging confirmed abscess reduction and inflammatory resolution (Fig.\u0026nbsp;2B). The patient completed the planned 6-week course of oral antibiotic therapy without reporting any adverse events.\u003c/p\u003e"},{"header":"Discussion and Conclusion","content":"\u003cp\u003eThis case describes a rare sequential complication: Klebsiella pneumoniae-induced nasopharyngeal abscess progressing to cavernous sinus syndrome and septic CVST. The patient\u0026rsquo;s poorly controlled diabetes mellitus was a critical predisposing factor, as hyperglycemia impairs immune cell function and facilitates invasive bacterial infection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].Diagnostic challenges arose from non-specific initial symptoms (headache, gait instability) that mimicked cerebrovascular disease. The key diagnostic turning point was the development of bilateral ophthalmoplegia, ptosis, eyelid edema, and chemosis \u0026mdash; classic manifestations of cavernous sinus pathology. Contrast-enhanced MRI was pivotal for identifying the nasopharyngeal abscess and cavernous sinus thrombosis, while tNGS and abscess culture confirmed Klebsiella pneumoniae as the etiologic agent. Notably, initial MRV was normal, which highlights that standard MRV may not always detect early septic thrombosis; clinical correlation with imaging and microbiology is essential.Management required a three-pronged approach: 1) Infection eradication with long-course, pathogen-targeted antibiotics (consistent with guidelines for severe Klebsiella pneumoniae infections [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]); 2) Anticoagulation for CVST (balancing thrombus propagation risk against bleeding risk, which resolved with treatment); 3) Comprehensive supportive care (glycemic/hypertensive control, nutritional support) \u0026mdash; critical for elderly frail patients. Surgical drainage of the nasopharynx abscess was not performed due to patient/family preference and significant clinical improvement with medical therapy alone. This case adds to the limited literature on Klebsiella pneumoniae-induced nasopharyngeal abscess complicated by CVST. It underscores that invasive Klebsiella pneumoniae should be considered in diabetic patients presenting with cranial neuropathies and systemic infection. Early contrast-enhanced MRI, tNGS (for rapid pathogen identification), and prompt initiation of antimicrobial therapy plus anticoagulation are key to preventing catastrophic neurological sequelae.\u003c/p\u003e\n\u003ch3\u003eStudy Limitations\u003c/h3\u003e\n\u003cp\u003eThis is a single-center retrospective case report with inherent selection bias and limited generalizability. Lack of long-term follow-up beyond 1 month precludes assessment of long-term neurological prognosis and recurrence risk and recurrence risk. Bacterial molecular characterization (e.g., virulence gene expression) and host genetic analysis were not performed, limiting insight into pathophysiological mechanisms. Conservative management of the abscess and anticoagulation in the setting of thrombocytopenia lack uniform guidelines, requiring validation by prospective multicenter studies.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCerebral Venous Sinus Thrombosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003etNGS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etargeted Next-Generation Sequencing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic Resonance Venography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCerebrospinal Fluid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-Reactive Protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProcalcitonin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWhite Blood Cell Count\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patient and his family for their informed consent and cooperation. We also acknowledge the support of the clinical laboratory and radiology departments of the Chinese People\u0026apos;s Liberation Army Navy No. 905 Hospital. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYujun Wu: Data collection, patient follow-up, manuscript writing (original draft), and revision. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDaojie Huang: Medical history collection, patient data management, clinical observation and outcome assessment, patient photograph acquisition, and manuscript revision. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYongqiu Zhang: Interpretation of cranial MRI findings, provision of imaging professional opinions, and manuscript review. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLiyan Gu: Research framework construction, project development, and manuscript proofreading. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJie Wei: Study design, research framework construction, supervision of data collection, and manuscript finalization. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Huashan Hospital Postdoctoral Training Program; the Naval Medical University \u0026quot;Zhuyuan\u0026quot; Talent Program (Grant No. 2022KYZ09); and the \u0026quot;Deep Blue Talent\u0026quot; Huashan Backbone Talent Project of the No. 905th Hospital of PLA Navy. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. The raw targeted next-generation sequencing (tNGS) data of cerebrospinal fluid and blood have been deposited in the NCBI Sequence Read Archive (SRA) database under the BioProject accession number PRJNA1403655\u003c/p\u003e\n\u003cp\u003eEthics Statement\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Chinese People\u0026apos;s Liberation Army Navy No. 905 Hospital (Approval No.2026-\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eEthical Opinion-LW07\u003c/strong\u003e\u003c/strong\u003e). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. All procedures were conducted in accordance with the Declaration of Helsinki. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from the patient. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no potential conflicts of interest, including financial, professional, or personal relationships related to the subject matter or materials discussed in the manuscript. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCoutinho JM, Zuurbier SM, Aramideh M, Stam J. The incidence of cerebral venous thrombosis: a cross-sectional study. Stroke. 2012;43(12):3375\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevasagayam S, Wyatt B, Leyden J, Kleinig T. Cerebral venous sinus thrombosis incidence is higher than previously thought: a retrospective population-based study. Stroke. 2016;47(9):2180\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaposnik G, Barinagarrementeria F, Brown RD Jr, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(4):1158\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerro JM, Bousser MG, Canh\u0026atilde;o P, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis \u0026mdash; endorsed by the European Academy of Neurology. Eur J Neurol. 2017;24(10):1203\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ene.13381\u003c/span\u003e\u003cspan address=\"10.1111/ene.13381\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiu LK, Yeh KM, Lin JC, Fung CP, Chang FY. Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet Infect Dis. 2012;12(11):881\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFang CT, Lai SY, Yi WC, et al. Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis. 2007;45(3):284\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun R, Zhang H, Xu Y, et al. Klebsiella pneumoniae-related invasive liver abscess syndrome complicated by purulent meningitis: a review of the literature and description of three cases. BMC Infect Dis. 2021;21:15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to sinusitis: are anticoagulants indicated? A review of the literature. J Laryngol Otol. 2002;116(9):667\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Q, Wang P, Shen M, Shan C. Clinical characteristics and risk factors for Klebsiella pneumoniae bloodstream infection in 152 immunocompetent patients. J Infect Developing Ctries. 2024;18(2):219\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3855/jidc.18204\u003c/span\u003e\u003cspan address=\"10.3855/jidc.18204\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cerebral venous sinus thrombosis, Cavernous sinus syndrome, Klebsiella pneumoniae, Nasopharyngeal abscess, Diabetes mellitus, case report༛","lastPublishedDoi":"10.21203/rs.3.rs-8653905/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8653905/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCerebral venous sinus thrombosis (CVST) is a rare but severe cerebrovascular disorder. While often associated with hypercoagulable states, infections, particularly those involving the head and neck region, can be a significant predisposing factor. Klebsiella pneumoniae is a known pathogen causing invasive syndromes, including liver abscesses and metastatic infections, but its association with nasopharyngeal abscess leading to CVST and cavernous sinus syndrome is exceptionally rare, especially in elderly patients with complex medical backgrounds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe report the case of a 77-year-old Chinese male with a history of hypertension and type 2 diabetes (poorly controlled), who presented with a 27-day history of paroxysmal headache and 10 days of progressive lethargy and gait instability. He subsequently developed bilateral eyelid ptosis, eyelid edema, chemosis, and ophthalmoplegia. Imaging studies identified a nasopharyngeal abscess with associated cavernous sinus thrombosis. Microbiological analysis of nasopharyngeal abscess fluid and blood targeted next-generation sequencing (tNGS) confirmed Klebsiella pneumoniae as the causative organism. The patient was managed with a multidisciplinary approach involving prolonged intravenous antibiotic therapy (Initially, meropenem and teicoplanin were administered; subsequently, the antibiotics were switched to levofloxacin and piperacillin-tazobactam based on the results of antimicrobial susceptibility testing ), anticoagulation, intensive glycemic and blood pressure control, and nutritional support. After a 22-day hospitalization, his symptoms significantly improved, inflammatory markers normalized, and he was discharged on a 4–6 week course of oral antibiotics (levofloxacin and piperacillin-tazobactam formulation).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case highlights a rare life-threatening complication of Klebsiella pneumoniae-induced nasopharyngeal abscess progressing to septic cavernous sinus thrombosis and cavernous sinus syndrome in an elderly immunocompromised patient with diabetes. It underscores the importance of considering invasive Klebsiella pneumoniae infection in the differential diagnosis of cranial neuropathies and CVST, particularly in patients with poor glycemic control. Early recognition, aggressive antimicrobial therapy, and anticoagulation are crucial for favorable outcomes.\u003c/p\u003e","manuscriptTitle":"Cerebral venous sinus thrombosis secondary to nasopharyngeal abscess with Klebsiella pneumoniae infection in an elderly patient with multiple comorbidities: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 14:58:21","doi":"10.21203/rs.3.rs-8653905/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-30T11:16:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T06:43:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2026-03-23T16:04:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-15T17:04:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T00:47:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221295302346237964933244766669206358459","date":"2026-02-11T23:41:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23236229019808476255972572625397604206","date":"2026-02-06T11:04:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T23:31:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-22T07:52:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T13:06:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-21T13:04:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2026-01-21T01:08:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4c5ff12d-0933-4df6-af3c-3f20577fff54","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T14:56:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 14:58:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8653905","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8653905","identity":"rs-8653905","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}