Case Presentation: A healthy 22-year-old presented with four days of acute onset emesis, jaundice, and fever. Four days prior to presentation, the patient ate fried chicken and rice for lunch. Four hours later he had twelve episodes of non-bilious non-bloody vomiting, without associated diarrhea or abdominal pain. Over the next three days, he developed progressive jaundice and a generalized headache. He denied any rash, joint aches, cough, sore throat, photophobia, or neck stiffness. Travel history was negative. He had no known tick or mosquito bites. He reported being up to date with vaccinations. Patient emigrated from Thailand 3 years ago to Ohio until a recent move to New York. Sexual history was notable for sex with men with consistent condom use, monogamy for the past six months, and no known HIV exposures. He denied illicit drug use. On admission, the patient’s vital signs were notable for a blood pressure of 90/53, heart rate of 143, and a fever of 100.4℉. Physical exam demonstrated scleral icterus, supple neck, no tonsillar exudates, benign abdominal exam, and no rash. Lab findings revealed WBC 20.56 K/uL, Hgb 10.7 g/dL, and Plt 73 K/uL, all new compared with blood work several months prior. Complete metabolic panel showed total bilirubin 6.4 mg/dL, direct bilirubin 3.4 mg/dL, ALP 189 U/L, and normal AST and ALT. HIV negative. Ultrasound of the abdomen as well as CT scan of the abdomen and pelvis did not reveal a source of infection. The patient was started on empiric piperacillin/tazobactam with clinical improvement as well as laboratory improvement in hyperbilirubinemia, leukocytosis and thrombocytopenia. Blood cultures revealed Fusobacterium necrophorum. Ultrasound of the jugular veins showed no thrombus. Repeat review of the admission CT scan revealed a peripheral hepatic vein thrombosis. Repeat ultrasound of portal and hepatic veins on the fourth day of admission showed no thrombus. The patient improved with antibiotics and was discharged on amoxicillin-clavulanate to complete a 14-day course.

Discussion: Fusobacterium necrophorum is a species of anaerobic gram-negative rod that is found in the alimentary tract and female genitourinary tract. This bacterium is perhaps most known for causing Lemierre’s syndrome, a septic thrombophlebitis of the internal jugular vein. Inflammation from the inciting pharyngitis or tonsillitis is thought to facilitate bacterial translocation across the mucosa, which then spreads to the nearby internal jugular vein. This case is unique as our patient did not have a sore throat or neck pain. Rather, he presented with emesis, jaundice, and a mixed hyperbilirubinemia in the setting of several days of gastroenteritis symptoms. These symptoms suggested involvement of the liver, which was later confirmed with hepatic vein thrombosis. Fusobacterium necrophorum thrombophlebitis in the hepatic vasculature is a rare phenomenon. There have only been a few case reports of hepatic vein thrombosis caused by Fusobacterium necrophorum and this case illustrates an uncommon presentation of a relatively uncommon illness.

Conclusions: In a patient with Fusobacterium necrophorum, it is important to consider alternative locations of septic thrombophlebitis beyond the classic location in the internal jugular vein to identify locations of potential thrombosis that correlate with the patient’s symptoms and lab findings.

IMAGE 1: Fig 1. CT abdomen and pelvis showing peripheral hepatic vein thrombosis.