Case Presentation: 50-year-old male with past medical history of hypertension, was diagnosed with a Warthin’s tumor. Patient underwent superficial parotidectomy with right neck lymph node dissection level. On POD #10, he presented to the ED for monomorphic ventricular tachycardia. He was cardioverted and started on amiodarone and flecainide with acceptable response. Increased swelling, tenderness, and purulent drainage was noted over right parotid region. CT neck with IV contrast showed occlusive thrombosis of the right internal jugular vein with intravascular gas concerning for thrombophlebitis; thrombosis was extending to right sigmoid sinus and distal transverse sinus. Culture from JP drain grew MRSA and he was started on IV Vancomycin & Unasyn. Patient was subsequently transitioned to oral antibiotics and discharged in a stable condition.
Discussion: Andre Lemierre first reported Lemierre’s syndrome in 1936 when he published a case series of 20-cases of throat infections with anaerobic septicemia. We describe a case of septic thrombophlebitis of internal jugular vein occurring after parotidectomy treated with antibiotics. Karkos et al published a systematic review of eighty-four studies from 1950 to 2007. This review showed that the tonsils were the most common source of infection followed by pharynx/URI. Fusobacterium necrophorum (gram-negative anaerobe) is the most commonly implicated organism, however cases with Streptococcus, Bacteroides, Staphylococcus, and Klebsiella have been reported. Diagnosis is usually with contrast-enhanced CT, ultrasound, or MRA. Treatment consists of targeted antibiotics with or without surgical drainage. Lemierre’s disease has been associated with coagulopathy, hence anticoagulation therapy should be considered. This does remain controversial as there are no randomized clinical trials, and it is used according to physician preference on a case-by-case basis. If untreated, Lemierre’s disease could lead to septic emboli, sepsis and DIC. This case is unique and prompts physicians to recognize an unrecognized complication of parotidectomy.
Conclusions: Lemierre’s syndrome is characterized by oropharyngeal infection leading to septic thrombophlebitis of jugular vein. Anaerobic organisms usually cause it. We report a case of post-parotidectomy Lemierre’s syndrome due to methicillin-resistant Staphylococcus aureus (MRSA). It is prudent for physicians to recognize septic thrombophlebitis as a complication of oro-pharyngeal surgery.