Dear Editor,

We read with interest the article entitled ‘Cerebral Venous Sinus Thrombosis in a Patient with Meningococcal Meningitis’, published in the January 2018 issue of the Oman Medical Journal.1

Bacterial meningitis is a life-threatening condition, and Neisseria meningitidis is a major cause. Cerebrovascular complications can occur. Cerebral venous sinus thrombosis (CVST) is a rare type of these complications, especially in meningococcal meningitis.2 According to Virchow’s classification, causes of CVST can be categorized into three main groups according to hypercoagulation state, blood flow disturbances, and infection or inflammation. Also, multiple risk factors can be found in patients with CVST.3 Hence, a thorough study of other causes should be done even if a specific risk factor is identified. In the presence of some prothrombotic conditions, the risk of CVST increases when exposed to infection. For example, a case of CVST complicating meningococcal meningitis has been reported.4 Thrombophilic study revealed hyperhomocysteinemia and methylenetetrahydrofolate reductase variants

(C677T and A1298C). The authors’ opinion was that this predisposing thrombophilic condition to CVST might be triggered by a central nervous system infection such as meningitis.4 Hence, thrombophilic evaluation in patients diagnosed with CVST seems necessary although, in the reported case, meningococcal meningitis was the most probable cause for CVST. The authors did not mention performing any thrombophilic evaluation, which seemed necessary in their patient.

references

1. 1. Chirakkara SK, Bakhsh AR, Pariyadath AK, Rathinavelu B. Cerebral venous sinus thrombosis in a patient with meningococcal meningitis. Oman Med J 2018 Jan;33(1):
   61-64.
2. 2. Heckenberg SG, de Gans J, Brouwer MC, Weisfelt M, Piet JR, Spanjaard L, et al. Clinical features, outcome, and meningococcal genotype in 258 adults with meningococcal meningitis: a prospective cohort study. Medicine (Baltimore) 2008 Jul;87(4):185-192.
3. 3. Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F; ISCVT Investigators. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 2004 Mar;35(3):664-670.
4. 4. Bozzola E, Bozzola M, Colafati GS, Calcaterra V, Vittucci A, Luciani M, et al. Multiple cerebral sinus thromboses complicating meningococcal meningitis: a pediatric case report. BMC Pediatr 2014 Jun;14:147..