Chest Infections: Student/Resident Case Report Poster - Chest Infections I |

A Case of Lemierre's Syndrome That Is Hard to Forget FREE TO VIEW

Lucas Cruz, MD; Denise Francisco, MD; Ausia Iqbal, MD
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University of Connecticut, Farmington, CT

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):177A. doi:10.1016/j.chest.2016.08.186
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SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Lemierre's syndrome, also known as suppurative thrombophlebitis of the jugular vein has been referred to as “The Forgotten Disease” due to the rapid decline in it's incidence after the advent of antibiotics. The occurrence of pneumothoraces is rarely seen with it.

CASE PRESENTATION: A 34-year-old male with a history of intravenous heroin abuse was admitted to the hospital with complaints of severe bilateral neck pain stiffness, fevers and facial swelling and tenderness. A computerized tomography of the head, neck and chest had shown a thrombus in the right internal jugular vein, extending to the proximal right subclavian vein as well as septic emboli in the lungs bilaterally without any head or neck abscesses identified. The patient was soon intubated due to progressive trismus. He was started on a heparin infusion and ampicillin-sulbactam which was switched to vancomycin after patient's blood cultures grew Community-Acquired Methicillin Resistant Staphylococcus aureus (CA-MRSA). He eventually developed sudden hypoxemia and was found to have a tension pneumothorax which was treated with insertion of a chest tube. Afterwards, patient developed new bilateral pneumothoraces, requiring repeated chest tubes making it difficult to ventilate him even on maximal ventilator settings. A decision was made by the family to withdrawal agressive care on day 10 of hospitalization and patient expired shortly after.

DISCUSSION: Lemierre's syndrome is a life threatening condition associated with significant morbidity and mortality. It is typically preceeded by oropharyngeal infections and classically caused by Fusobacterium necrophorum. Our case is atypical in several ways, with no involvement of oropharynx at any point. The most likely source of his infection, which was caused by CA-MRSA, appeared to be his facial skin infection. This organism is rarely associated with this syndrome with few cases reported in the literature. The occurrence of bilateral, recurrent, refractory pneumothoraces also appears to be very rarely associated with this syndrome, even though septic pulmonary emboli are the most common metastatic complication of the disease. At the end, our patient's clinical deterioration was mostly driven his worsening respiratory status and inability to effectively ventilate him.

CONCLUSIONS: A high degree of suspicion is needed to promptly diagnose Lemierre's syndrome. The management can be challenging, especially in the setting of atypical presentations and complications as demonstrated in our case.

Reference #1: Chirinos JA et al. The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore). 2002

Reference #2: Abhishek A et al. Lemierre syndrome from a neck abscess due to methicillin-resistant staphylococcus aureus. Braz J Infect Dis. 2013

Reference #3: V Kizhner et al. Methicillin-resistant Staphylococcus aureus bacteraemia associated with Lemierre's syndrome: case report and literature review. J Laryngol Otol, 2013

DISCLOSURE: The following authors have nothing to disclose: Lucas Cruz, Denise Francisco, Ausia Iqbal

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