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Atypical Case of Lemierre's Syndrome FREE TO VIEW

Nashwa Abdulsalam, MD; Farrukh Abbas, MD; Gbolahan Ogunbayo, MD
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Rochester General Hospital, Rochester, NY

Chest. 2015;148(4_MeetingAbstracts):284A. doi:10.1378/chest.2265888
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SESSION TITLE: Critical Care Student/Resident Case Report Posters III

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Lemierre’s syndrome is defined as suppurative thrombophlebitis of internal jugular vein. It is frequently preceded by pharyngotonsillitis, dental infection or infectious mononucleosis. It is characterized by fever, sepsis, septic pulmonary emboli and can be complicated by empyema. The causative organisms are usually normal oropharyngeal flora. Fusobacterium necrophorum is the most common pathogen involved. We report an unusual presentation of Lemierre’s syndrome in which evidence of suppurative thrombophlebitis of internal jugular vein was not found on presentation.

CASE PRESENTATION: 23 year old previously healthy man presented to the emergency department with fever, chills, right sided chest pain and shortness of breath since 5 days. He gave history of sore throat about a week ago which was treated with antibiotics on outpatient basis. His history was also significant of neck contusion and neck pain lasting for 2 days about one week ago which had resolved till date. Physical examination: Temperature 39.3 C, heart rate 110/min, blood pressure 75/43 mmHg. Lung auscultation was remarkable for decreased breath sounds and bilateral rales on lung bases. His labs showed creatinine 1.9 mg/dL (baseline 0.6 mg/dL), WBC 25,700 u/L with neutrophils 23,900 u/L, lactic acid 6.4 mmol/L. He was admitted to intensive care unit for the management of septic shock needing vasopressors and mechanical ventilation for respiratory failure. CT scan chest revealed multi-lobar airspace disease with associated cavitation consistent with multi-lobar pneumonia and septic emboli. His pneumonia was complicated by left sided empyema needing decortication. Blood cultures grew Fusobacterium necrophorum and Streptococcus constellatus. Ultrasound and CT scan neck with IV contrast were negative for any evidence of jugular vein thrombosis. Transthoracic echocardiography did not show any evidence of endocarditis. He was treated with broad spectrum antibiotics initially which were de-escalated based on culture and sensitivity data. The patient recovered from septic shock and respiratory failure in about 5 days.

DISCUSSION: Lemierre’s syndrome is a rare but potentially life threatening complication of acute pharyngotonsillitis. We think our patient’s presentation does not fit any diagnosis other than Lemierre’s syndrome given antecedent pharyngitis, septic pulmonary emboli and characteristic bacteremia. Although there was no evidence of suppurative thrombophlebitis on neck imaging but his history of neck contusion and pain few days before presentation might have been due to thrombophlebitis.

CONCLUSIONS: Lemierre's syndrome can present late with no evidence of suppurative thrombophlebitis on imaging but with all other clinical manifestations.

Reference #1: Riordan T, Wilson M. Lemierre's syndrome: more than a historical curiosa. Postgrad Med J 2004; 80:328

DISCLOSURE: The following authors have nothing to disclose: Nashwa Abdulsalam, Farrukh Abbas, Gbolahan Ogunbayo

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