INTRODUCTION:Fever with sore throat, cervical lymphadenopathy, pleuritic pain, pleural effusions and pulmonary infiltrates has a broad differential which includes atypical pneumonia, bacterial pneumonia, leptospirosis, viral phayrngitis and infectious mononucleosis. Septic pulmonary emboli (SPE) is an uncommon but serious disorder that may be difficult to recognize. Outcomes of patients with SPE have changed over the past 30 years. This case illustrates an uncommon cause for SPE.
CASE PRESENTATION:A 17-year-old girl presented with a 1 week history of intermittent high fevers, sore throat, vomiting, and lightheadedness. Her medical history included mild intermittent asthma and bronchitis. She was initially treated as an outpatient for a viral syndrome. As she developed labored breathing, pleuritic chest pain and worsening fever and dyspnea over the next few days, she was admitted to the local hospital for further management. On admission she had leukocytosis, cholestasis, and bilateral pulmonary infiltrates. She was treated with broad-spectrum antibiotics (meropenem, vancomycin, doxycycline, and levofloxacin) and transferred to our intensive care unit (ICU) for worsening respiratory distress and sepsis. On transfer to our facility, examination revealed a toxic appearing, tachycardic and tachypneic girl in obvious respiratory distress requiring non-invasive mechanical ventilation. Physical exam revealed erythematous swollen tonsils with bilateral tender lymphadenopathy and diffuse crackles in both lung fields on auscultation. Chest computerized tomography (CT) scan showed multiple cavitary pulmonary lesions and left pleural effusions (Figure 1). CT scan of the neck showed findings consistent with a nonocclusive thrombus in the right internal jugular vein (Figure 2). Based on the clinical history of a recent oropharyngeal infection and the presence of internal jugular vein thrombosis with multiple pulmonary septic emboli, the diagnosis of Lemierre syndrome was suspected and later confirmed with bronchial washings by bronchoscopy positive for Fusobacterium necrophorum. Blood cultures were negative as the patient was started on antibiotics prior to obtaining the blood cultures. After prolonged treatment with tailored antibiotic therapy and therapeutic thoracentesis of the bilateral exudative effusions, the patient achieved a remarkably full recovery with restoration of pulmonary functions. Our patient was thought to have Lemierre syndrome with Fusobacterium pharyngitis that led to seeding of the right internal jugular and subsequent septic pulmonary emboli. She was treated with a two-week course of Moxifloxacin and a six-week course of Ertrepenem with complete resolution on follow-up.
DISCUSSIONS:Lemierre’s syndrome or jugular vein suppurative thrombophlebitis is a rare disorder with less than 160 cases reported since 1900s. It is most often associated with pharyngitis frequently with peritonsillar involvement. The thrombophlebitis presents within a week of the orphyrangeal infection with the infection extending from the parapharyngeal space to the jugular vein via the carotid sheath. It often affects healthy young adults although it has been reported in patients with recent surgery and multi-organ failure. Though, it may be potentially fatal if the diagnosis is missed, it is highly curable and responsive to prompt antibiotic therapy. Typical presentation includes high fevers, pain, and swollen tender neck resulting in respiratory distress. Septic pulmonary emboli are found in 97% of cases. Metastatic abscesses may also occur at other sites.
CONCLUSION:Lemierre’s syndrome should be considered in any patient with septic pulmonary emboli and persistent fever despite antimicrobial therapy, who initially present with oropharyngeal infection.
DISCLOSURE:Akram Khan, No Financial Disclosure Information; No Product/Research Disclosure Information