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Chest Infections |

Another Case of a Sore Throat…To Give or Not to Give Antibiotics?

Tiffany Dumont, DO; Rajashekar Adurty, MD; Marvin Balaan, MD; Bille Jo Barker, MD
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Allegheny General Hospital, Pittsburgh, PA


Chest. 2013;144(4_MeetingAbstracts):187A. doi:10.1378/chest.1698743
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Abstract

SESSION TITLE: Infectious Disease Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Prior to the pre-antibiotic era Lemierre’s syndrome was common, with the advent of antibiotics the number of cases lessened. In the last fifteen years nonetheless the number of cases is on rise, possibly due to our over reliance on the streptococcal rapid antigen detection test (RADT) or our reluctance to prescribe antibiotics for sore throat?

CASE PRESENTATION: An 18-year-old male, with a history of recurrent pharyngitis, presented with sore throat, fever, and shortness of breath for 10 days. He had been seen in the outpatient clinic, a Monospot and streptococcal RADT were negative. He was given a prescription for steroids which he took for 2 days prior to admission. The patient had no sick contacts, no recent travel, no history of intravenous drug use, and was not taking any medication. On arrival the patient was in respiratory distress and was intubated. On exam he was febrile, tachycardic, blood pressure 95/37, 98% on mechanical ventilation with 80% Fi02 with scattered rhonchi. CT scan of the chest showed multifocal pulmonary consolidations and nodules. White blood cell count 24 k/mcL, platelets 26 k/mcL Creatinine 2.65 mg/dL. Transesophageal echo was negative. Blood cultures revealed Fusobacterium Necrophorum, Group F Streptococci, and Gemella. Ultrasound of the neck revealed a thrombus in the right internal jugular vein. The patient had previously been treated with ampicillin sulbactam, gentamicin was then added.

DISCUSSION: Lemierre’s syndrome is commonly preceded by pharyngitis and in most cases, tonsillar or peritonisillar involvement. Causative organisms include Fusobacterium necrophorum, other Fusobacterium species, Eikenella corrodens, Porphyromonas asaccharolytica, Streptococci including S. pyogenes, Bacteroides. In the past 15 years we have seen a resurgence of Lemierre’s syndrome. One must consider the use of the streptococcal RADT and the reduction in the number of antibiotics prescribed for sore throat as a potential cause. The RADT sensitivity ranges from 70-90% and the specificity from 90-100%. Fusobacterium will not grow on the aerobic medium which is used for throat cultures. Clinicians should consider Fusobacterium in young adults with a negative RADT whose pharyngitis is severe or prolonged.

CONCLUSIONS: Physicians must be mindful that a negative streptococcal RADT does not exclude a bacterial cause and the whole clinical picture must be taken into account.

Reference #1: Seidenfeld SM, Sutker WL, Luby JP. Fusobacterium necrophorum septicemia following oropharyngeal infection. JAMA 1982; 248:1348.

Reference #2: Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev 2006; CD000023.

DISCLOSURE: The following authors have nothing to disclose: Tiffany Dumont, Rajashekar Adurty, Marvin Balaan, Bille Jo Barker

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