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Postgraduate Education Corner: Ultrasound Corner |

A Teenager With Fever and Sore ThroatTeenager With Fever and Sore Throat FREE TO VIEW

Jose Cardenas-Garcia, MD; Mangala Narasimhan, DO, FCCP; Seth J. Koenig, MD, FCCP
Author and Funding Information

From the Department of Pulmonary, Critical Care, and Sleep Medicine, Hofstra North Shore-LIJ School of Medicine, Oakland Gardens, NY.

Correspondence to: Jose Cardenas-Garcia, MD, Hofstra North Shore-LIJ School of Medicine, Department of Pulmonary, Critical Care, and Sleep Medicine, 410 Lakeville Rd, Lake Success, NY 11042; e-mail: jdecardenasg@gmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(4):e10-e13. doi:10.1378/chest.13-2260
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Published online

A male teenager presented to the ED complaining of fevers and a sore throat for 1 week. He had previously visited his primary care physician and received a 3-day course of azithromycin without improvement. The initial ED visit showed a normal chest radiograph and unremarkable physical examination; blood was drawn, and he was sent home with a prescription for acetaminophen. The next day his blood cultures grew gram-negative rods, and he was called to return to the ED for follow-up care. He now complained of a worsening sore throat and odynophagia. He had a mild nonproductive cough with no dysphonia, trismus, or neck pain. Review of other systems was normal. Of note, he had no recent dental procedures.

On physical examination in the ED, initial vital signs were as follows: BP, 90/60 mm Hg; heart rate, 120 beats/min; temperature, 39.7°C; and oxygen saturation, 93% on 2 L of supplemental oxygen. He had bilateral painful cervical lymphadenopathy, no rashes, and normal oropharynx; his dental examination was unremarkable. Lung auscultation revealed bilateral fine rales on bases. Laboratory results showed leukocytosis (13,400 cells/μL) with 90% of neutrophils and thrombocytopenia (75,000 cells/μL); his basic metabolic panel and liver function panel results were unremarkable. A chest radiograph on the second ED visit was read as “clear lungs” (Fig 1). The medical ICU was consulted for management of presumed sepsis, and after a history and physical examination a goal-directed ultrasound examination was performed, as seen in the patient videos.

Figure Jump LinkFigure 1. Normal chest radiograph on admission.Grahic Jump Location
After reviewing this patient’s history, physical examination, and ultrasound images, what is the most likely diagnosis?
Answer: Deep soft tissue infection secondary to Fusobacterium necrophorum (Lemierre syndrome) causing right internal jugular thrombosis, septic emboli to the lungs, and septic shock.

Discussion Video

Ultrasound used to diagnose Lemierre Syndrome

Lemierre syndrome is a rare but serious illness that associates oropharyngeal infection involving the palatine tonsils or peritonsillar tissue and thrombosis of the internal jugular vein (IJV). There is a 1- to 3-week time interval1 during which distant septic pulmonary and systemic emboli occur. Lemierre syndrome commonly occurs in young adults and is mainly caused by Fusobacterium necrophorum,2,3 an anaerobic gram-negative bacillus that is part of the normal oral flora. However, other organisms, including Bacteroides, Eikenella, Streptococcus, Peptostreptococcus, Porphyromonas, Prevotella, Proteus, methicillin-resistant Staphylococcus aureus, and methicillin-sensitive S aureus may also cause Lemierre syndrome.4,5

A goal-directed ultrasound examination was performed in this patient with gram-negative sepsis and shock. Because of the patient’s painful cervical lymphadenopathy, the vessels of the neck were imaged.

Discussion Videos 1-8

Videos 1 through 8 show the ultrasound guided examination

Running Time: 3:00

Videos 1 and 2 show the IJV with a hyperechoic mass inside the lumen without movement suggestive of a thrombus. A thrombosed IJV is rarely palpable, and local signs of venous inflammation and thrombosis may be absent, especially if the inflammation spreads from the posterior-lateral pharyngeal space.6 The ultrasound diagnosis of a venous thrombosis is made by simple observation of a regular-shaped echoic mass inside the venous lumen or by the inability to fully compress the vein. A CT scan with contrast of the neck (Figs 2, 3) was subsequently obtained in this patient and showed an 8-mm right deep tonsillar abscess and a nonocclusive right internal jugular thrombus.

Figure Jump LinkFigure 2. CT scan of the neck revealing an 8-mm abscess with peripheral enhancement in the deep right tonsillar soft tissues (arrow).Grahic Jump Location
Figure Jump LinkFigure 3. CT scan of the neck showing a tubular filling defect in the right internal jugular vein at level of right submandibular region with surrounding edema, stranding, and fluid.Grahic Jump Location

Because of significant hypoxemia and lung auscultation findings, thoracic ultrasound was performed. This showed bilateral focal B-lines, consistent with interstitial syndrome. B-lines are characterized as discrete laser-like vertical hyperechoic lines that arise from the pleural line, extend to the bottom of the screen without fading, and move synchronously with pleural sliding. B-line predominance is defined by the presence of three or more B-lines in a longitudinal plane between two ribs. Diffuse interstitial syndrome is found in cardiogenic pulmonary edema, interstitial pneumonia, acute lung injury, and diffuse parenchymal lung disease. Focal/multifocal B-lines may be seen in the presence of many lung diseases (eg, pneumonia, pulmonary contusion, atelectasis, pulmonary infarction, parenchymal microabscesses, and cavitations), as was in our case. The characteristics of the pleura itself may also be important. Emerging data suggest that infectious or inflammatory lung disease will reveal a “coarse” pleural surface vs the characteristically smooth pleura seen with B-lines secondary to congestive heart failure7 (Fig 4). Video 3 reveals focal B-lines in multiple areas of the examined lungs and is suggestive of septic emboli producing cavitary lesions and microabscesses in light of the clinical information and in the presence of a documented thrombus in IJV. Video 4 clearly shows within the same scanning field an area of normal pleural and A-lines next to an area of irregular pleural surface and B-lines. The irregular pleura is immediately adjacent to an area of echogenicity and lucency, consistent with subpleural small abscess formation and microcavitation. This highlights the focal nature of the process.

Figure Jump LinkFigure 4. A, B, Pleural line. Note the smooth pleural line characteristic of fluid overload (A) vs the “coarse” pleura suggesting an inflammatory/infectious process (B).Grahic Jump Location

Lemierre syndrome has been associated with several pulmonary complications, including bilateral necrotic pleuropulmonary emboli, pleural effusions, empyema, and abscesses. Septic emboli are the most common complication, accounting for up to 97% of the complications in cases of Lemierre syndrome.8 CT scan of the chest confirmed our ultrasound findings (Figs 5, 6) of abscess formation.

Figure Jump LinkFigure 5. Small subpleural alveolar consolidation/abscess (arrow) in the right middle lobe corresponding to the ultrasound image in Video 4.Grahic Jump Location
Figure Jump LinkFigure 6. CT scan of the chest showing multiple patchy, nonenhancing air space opacities located in a peripheral, subpleural location throughout both lungs, most predominant at the lung bases (arrows).Grahic Jump Location

A goal-directed echocardiogram was performed in this patient with hypotension and gram-negative bacteremia who needed intubation at his arrival to our unit. Videos 5 to 8 show normal left ventricular function and an inferior vena cava with marked respiratory variation, suggesting a preload responsive state. This supported the diagnosis of distributive shock from sepsis and demonstrated that the patient was in a fluid-responsive state.9 Other causes of this patient’s shock state were immediately ruled out, such as pulmonary embolus (right ventricle is smaller then left ventricle), pericardial effusion (absence of fluid surrounding the heart), or left ventricular dysfunction (overall normal and symmetrical contraction of the left ventricle).

Some authors3,5 suggest that when Lemierre syndrome is suspected, the best immediate diagnostic modality is a CT scan of the neck with contrast, allowing visualization of both the lumen of the IJV and any soft tissue swelling or abscess formation. However, we believe that a screening ultrasound of the neck may allow the treating physician immediate diagnostic information. The role of ultrasound should not be underestimated, since it is easily accessible, less invasive, and cost-effective, with good imaging capability of the internal jugular vein.10 It should be noted, however, that ultrasound lacks sensitivity when the thrombus is located below the deep mandible or underneath the clavicle.1,5 In our case, goal-directed ultrasonography helped us to make the diagnosis of Lemierre syndrome, identifying the septic emboli causing cavitary lesions within the lung, and categorized his shock as distributive to guide the administration of fluids.

The management of Lemierre syndrome includes supportive care of the patient, surgical drainage of pharyngeal or mediastinal collections, and broad-spectrum antibiotics (piperacillin-tazobactam or carbapenems). This patient was on mechanical ventilation, was aggressively fluid resuscitated, received meropenem, and underwent elective drainage of his abscess. He was extubated on day 3 of medical ICU admission and made a complete recovery.

  • 1. The presence of an echoic mass within the lumen of the IJV is sufficient to make the diagnosis of a thrombus. If simple observation is negative, and clinical suspicion for a thrombus is high, compression maneuvers of the vein should be performed.

  • 2. Identification of IJV thrombus in the setting of acute pharyngitis and clinical picture of sepsis suggests a possibility of Lemierre syndrome.

  • 3. Subpleural microabscesses and cavitary lesions from septic emboli may be readily seen with ultrasound. The pleural surface may appear “coarse” and is indicative of an infectious or an inflammatory process.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online article.

Hughes CE, Spear RK, Shinabarger CE, Tuna IC. Septic pulmonary emboli complicating mastoiditis: Lemierre’s syndrome revisited. Clin Infect Dis. 1994;18(4):633-635. [CrossRef]
 
Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre’s syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012;12(10):808-815. [CrossRef]
 
Righini CA, Karkas A, Tourniaire R, et al. Lemierre syndrome: a study of 11 cases and literature review [published online ahead of print June 19, 2013]. Head Neck. doi:10.1002/hed.23410.
 
Chanin JM, Marcos LA, Thompson BM, et al. Methicillin-resistantStaphylococcus aureusUSA300 clone as a cause of Lemierre’s syndrome. J Clin Microbiol. 2011;49(5):2063-2066. [CrossRef]
 
Riordan T. Human infection withFusobacterium necrophorum(Necrobacillosis), with a focus on Lemierre’s syndrome. Clin Microbiol Rev. 2007;20(4):622-659. [CrossRef]
 
Goldhagen J, Alford BA, Prewitt LH, Thompson L, Hostetter MK. Suppurative thrombophlebitis of the internal jugular vein: report of three cases and review of the pediatric literature. Pediatr Infect Dis J. 1988;7(6):410-414. [CrossRef]
 
Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound. 2008;6:16. [CrossRef]
 
Golpe R, Marín B, Alonso M. Lemierre’s syndrome (necrobacillosis). Postgrad Med J. 1999;75(881):141-144.
 
Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide diagnosis and therapy. Chest. 2012;142(4):1042-1048. [CrossRef]
 
Nadir NA, Stone MB, Chao J. Diagnosis of Lemierre’s syndrome by bedside sonography. Acad Emerg Med. 2010;17(2):E9-E10. [CrossRef]
 

Figures

Figure Jump LinkFigure 1. Normal chest radiograph on admission.Grahic Jump Location
Figure Jump LinkFigure 2. CT scan of the neck revealing an 8-mm abscess with peripheral enhancement in the deep right tonsillar soft tissues (arrow).Grahic Jump Location
Figure Jump LinkFigure 3. CT scan of the neck showing a tubular filling defect in the right internal jugular vein at level of right submandibular region with surrounding edema, stranding, and fluid.Grahic Jump Location
Figure Jump LinkFigure 4. A, B, Pleural line. Note the smooth pleural line characteristic of fluid overload (A) vs the “coarse” pleura suggesting an inflammatory/infectious process (B).Grahic Jump Location
Figure Jump LinkFigure 5. Small subpleural alveolar consolidation/abscess (arrow) in the right middle lobe corresponding to the ultrasound image in Video 4.Grahic Jump Location
Figure Jump LinkFigure 6. CT scan of the chest showing multiple patchy, nonenhancing air space opacities located in a peripheral, subpleural location throughout both lungs, most predominant at the lung bases (arrows).Grahic Jump Location

Tables

Discussion Video

Ultrasound used to diagnose Lemierre Syndrome

Discussion Videos 1-8

Videos 1 through 8 show the ultrasound guided examination

Running Time: 3:00

References

Hughes CE, Spear RK, Shinabarger CE, Tuna IC. Septic pulmonary emboli complicating mastoiditis: Lemierre’s syndrome revisited. Clin Infect Dis. 1994;18(4):633-635. [CrossRef]
 
Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre’s syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012;12(10):808-815. [CrossRef]
 
Righini CA, Karkas A, Tourniaire R, et al. Lemierre syndrome: a study of 11 cases and literature review [published online ahead of print June 19, 2013]. Head Neck. doi:10.1002/hed.23410.
 
Chanin JM, Marcos LA, Thompson BM, et al. Methicillin-resistantStaphylococcus aureusUSA300 clone as a cause of Lemierre’s syndrome. J Clin Microbiol. 2011;49(5):2063-2066. [CrossRef]
 
Riordan T. Human infection withFusobacterium necrophorum(Necrobacillosis), with a focus on Lemierre’s syndrome. Clin Microbiol Rev. 2007;20(4):622-659. [CrossRef]
 
Goldhagen J, Alford BA, Prewitt LH, Thompson L, Hostetter MK. Suppurative thrombophlebitis of the internal jugular vein: report of three cases and review of the pediatric literature. Pediatr Infect Dis J. 1988;7(6):410-414. [CrossRef]
 
Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound. 2008;6:16. [CrossRef]
 
Golpe R, Marín B, Alonso M. Lemierre’s syndrome (necrobacillosis). Postgrad Med J. 1999;75(881):141-144.
 
Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide diagnosis and therapy. Chest. 2012;142(4):1042-1048. [CrossRef]
 
Nadir NA, Stone MB, Chao J. Diagnosis of Lemierre’s syndrome by bedside sonography. Acad Emerg Med. 2010;17(2):E9-E10. [CrossRef]
 
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