Case Presentation: Patient is a 51-year-old man who presented with complaints of progressively worsening dyspnea, productive cough, sore throat and intermittent fevers of about 1 week. He has a past medical history of tobacco use. Initial vitals showed a temperature – 100.5F, heart rate – 118 bpm ,blood pressure – 119mmhg/60mmhg , respiratory rate – 23cpm and SPO2 of 92% on 2L oxygen. He was acutely ill looking, with coarse breath sounds on lung exam. Examination of the other systems was unremarkable. Initial labs showed significant leukocytosis – 24.9 k/mm3 , normal hemoglobin, significant thrombocytopenia – 55 k/mm3 . He also had an acute kidney injury . CT scan of the chest at admission showed bilateral multiple ground glass opacities and areas of mass like consolidations in both lungs and also small areas of possible pulmonary embolism versus thrombosis.The patient was thought to have sepsis due to multifocal pneumonia and received broad spectrum antibiotics (vancomycin and meropenem). He was anticoagulated with enoxaparin for suspected pulmonary embolism. His clinical condition worsened with worsening respiratory failure requiring intubation and mechanical ventilation. Respiratory viral panel and covid -19 was negative. His blood cultures drawn at admission grew Porphyromonas asaccharolytica which prompted a CT scan of the neck and repeat scan of the chest which showed thrombus in the left internal jugular vein and cavitation in both lungs suspicious for septic emboli and the possibility of Lemierre’s syndrome. Transthoracic echocardiography done did not show vegetations.
Discussion: Lemierre’s syndrome is usually caused by oropharyngeal flora, most commonly the anaerobe Fusobacterium necrophorum. Porphyromonas asaccharolytica, although not commonly found in oral cavity, is an uncommon causative agent of lemierre’s syndrome. Pathophysiology of this syndrome is unclear, hypothesis is that, a preceding infection likely viral hinders the local defense and allows spread into pharyngeal space including the internal jugular vein. Metastatic infections to other sites such as lungs, bones, or brain usually occurs after this. Common complications include septic emboli to the lungs , lung abscess, pleural effusions, and/or empyema, septic arthritis, endocarditis , liver, skin and cerebral abscess. Our patient had septic emboli to his lungs and pleural effusions that required chest tube placement for drainage.Treatment of choice is with a prolonged course of antibiotics with penicillins, clindamycin, and/or metronidazole, usually for two- four weeks. Intravenous antibiotics is usually preferred. Surgical intervention such as Incision , drainage and ligation of the internal jugular vein is recommended for patients with persistent septic embolization despite antibiotics. There are no studies to evaluate role of anticoagulation and its use remains controversial. Anticoagulation is recommended if there is evidence of significant extension of thrombus with persistent bacteremia and/or uncontrolled clinical sepsis. Our patient was treated with IV antibiotics and he did very well. He did not have persistent bacteremia , was extubated and discharged to acute rehab to complete a 4 week course of antibiotics.
Conclusions: This case depicts that, although rare, Porphyromonas asaccharolytica may be a causative agent of Lemierre’s syndrome . Bacteremia with the above organism should therefore lead to a prompt evaluation for Lemierre’s syndrome.