Case Presentation

Case Presentation Myra Lalas

HPI • 16 yo male previously healthy who presented to the Peds ED with: • sore throat and dysphagia x 4 days • Fever x 3 days (Tm = 105.3) • L neck and shoulder pain x 1 day • Headache x 1 day • Decreased PO

NBNB emesis x 1 yesterday • Diarrhea 4 days ago • Hematuria • No abdominal pain • No rhinorrhea • No cough • No rash • No sick contacts • No recent travel

PMH • None • No known allergies • Shots UTD

FMH • noncontributory

HEADSS • Lives with both parents and brother. • In 11th grade • Denies EtOH, nicotine, illicit drugs • Sexually active, uses condoms, 3 SP’s, (-) STD history

PE • VS T 100 BP 110/54 P 128 R 28 99%RA • GEN Uncomfortable, has difficulty moving due to neck pain • HEENT NCAT, PERLLA, EOMI, MMM, OP clear, (+) L-sided tenderness to palpation, with some erythema • CHEST (+) rhonchi on R base • HEART N S1/S2, no murmurs

ABD soft, (+) BS, NT/ND, no HSM, no CVA tenderness • EXT FEP, CRT < 2 s • NECK no Kernig’s, no Brudzinski’s

LABS • CBC • Blood Culture • CMP • D dimer • Fibrinogen • Coags • UA • Urine culture

Imaging • CXR- normal • CT Scan Chest: multiple lesions in b/l lung fields • CT abd/pelvis for hematuria: (+) nodules at b/l lung fields • Neck US: b/l cervical LAD; (+) L IJV thrombus in superior cervical portion into tributary

ER Course • BP dropped to 90/40- received NS bolus x 2 • Peds ID consulted: thrombus likely infected and spreading septic emboli to lungs; showing signs of sepsis and DIC w/c may explain ARF and crea of 2.1 • Start Vanco, Flagyl, and Ceftriaxone

Differentials? • Cat scratch disease • Candidiasis • Cellulitis • Endocarditis • Mastoiditis • Pharyngitis • Sinusitis • Superficial thrombophlebitis

Lemierre’s Disease • Jugular vein thrombophlebitis • Usual sources of infection: • Tonsil • Pharynx/ URTI • Chest/ LRTI • Middle ear/ mastoid • Larynx • Dental • Paranasal sinus

Usual First Clinical Symptoms • Sore throat • Neck mass • Neck pain • Bone/ joint pain • Otalgia and/or otorrhea • Dental pain • Orbital pain • GI symptoms

Microbiology • Fusobacterium necrophorum • Other Fusobacterium sp. • Eikenella corrodens • Porphyromonas asaccharolytica • Streptococci including S. pyogenes • Bacteroides

Pathophysiology • Production of bacterial toxins (e.g., LPS) leads to secretion of cytokines by leukocytes- SEPTIC SYMPTOMS • Production of hemagglutinin- causes platelet aggregation that can lead to DIC and thrombocytopenia • Inflammation and septic thrombophlebitis gives rise to distant emboli that usu. migrate to pulmonary capillaries

Sites of Septic Mets • Lungs • Joints • Knee • Hip • Sternoclavicular joint • Shoulder • elbow

Diagnostics • High resolution CT Scan with contrast- probably the most useful investigation for jugular or vena caval suppurative thrombophlebitis and may demonstrate soft tissue swelling and filling defects or thrombus • Venography • US- not useful in regions deep to the clavicle or mandible

Treatment • removal of the initiating focus of infection (eg, intravenous catheter) • prompt initiation of high dose intravenous antibiotics • surgical consultation and intervention • consideration of anticoagulation.

Antibiotics • a beta-lactamase resistant beta-lactam antibiotic is recommended for the treatment of this infection: • Ticarcillin-clavulanate (3.1 g IV every four hours) or imipenem (500 mg to 1 g every six hours). • The duration of therapy generally is for at least four weeks or until pulmonary abscesses have resolved by CT scan.

Surgery • Surgical exploration, with ligation or excision of the internal jugular vein is occasionally required. • Surgical drainage of pulmonary abscesses or empyema may be necessary.

Anticoagulation • Remains controversial as its use has not been properly assessed due to the low incidence of the disease

References • Karkos et al. Lemierre’s syndrome: a systematic review. The Laryngoscope. 2009: The American Laryngological, Rhinological and Otological Society, Inc; pp. 1-8. • www.uptodate.com

Case Presentation