Case Presentation:
A 27‐year‐old man with no prior medical history presented to the emergency department (ED) for a 2‐day history of sore throat, nonproductive cough, and fever. Physical exam revealed pharyngeal erythema and cervical lymphadenopathy. He reported a penicillin allergy of a rash. The patient was diagnosed with pharyngitis and discharged on oral azithromycin. The next day, he was contacted for an abnormal chest X‐ray and advised to return. He now mentioned new‐onset worsening dyspnea. On arrival to the ED, the patient was febrile, hypotensive, and in severe respiratory distress. He was emergently intubated, fluids and pressors were started, and blood cultures were drawn, and he was begun on broad‐spectrum antibiotics. The WBC count was 24,000 cells/μL with a differential count of 94% granulocytes. The chest X‐ray now indicated new bilateral lung infiltrates consistent with acute respiratory distress syndrome. Forty‐eight hours later, gram stain of the blood indicated gram‐negative rods from only the anaerobic vial. Interim blood cultures grew Fusobacterium varium. The patient was desensitized to penicillin and started on intravenous penicillin G and moxifloxacin. A neck CT with contrast revealed lack of enhancement of the left internal jugular vein. Doppler ultrasound of the neck revealed left internal jugular vein thrombosis. The patient was diagnosed with Lemierre's syndrome. He was started on intravenous heparin. The patient improved and was subsequently extubated. He was discharged with an indwelling catheter on intravenous meropenem, subcutaneous low‐molecular‐weight heparin. and benadryl (penicillin allergy).
Discussion:
Lemierre's syndrome is a rare disorder of young adults caused by the anaerobic bacterium Fusobacierium necrophorum and sporadically by other Fusobacterium species. It is typified by primary oropharyngeal infection with evidence of septic thrombophlebitis, exhibited by positive blood cultures, clinical or radiographic evidence of internal jugular vein thrombosis, and at least 1 metastatic focus. Imaging of the internal jugular vein may be accomplished with ultrasound, CT, or MRI to establish the presence of thrombosis. Confirmation of Lemierre's syndrome is provided by demonstration of the Fusobacterium species in the anaerobic blood culture. The recommended treatment is combination therapy with parenteral high‐dose penicillin and metronidazole.
Conclusions:
More prudent antibiotic‐prescribing habits in upper respiratory tract infections attributed to viral etiologies may lead to the clinical reappearance of this often forgotten disease. Not only do antibiotics shorten the duration of symptoms related to bacterial pharyngitis, but they can also prevent suppurative complications. This case also illustrates the value of having anaerobic bottles in blood culture sets. Physicians should be aware of Lemierre's syndrome and consider it in the differential diagnosis of a young patient suffering from a fulminant oropharyngeal infection with a deteriorating clinical course.
Author Disclosure:
A. Kushawaha, none; M. Popalzai, none; E. El‐Charabaty, none; N. Mobarakai, none.