We report a 32 year old previously healthy Caucasian male who presented with fever and a sore throat. At presentation he was noted to be febrile, but examination of his throat and neck were unremarkable. Blood cultures were positive for Fusobacterium necrophorum in two sets. CT of his neck was negative for parapharyngeal abscesses or thrombophlebitis but did show a carious maxillary tooth with a periapical abscess. Multiple solid and cavitary lesions were also visualized in the upper lung fields concerning for metastatic abscesses. Dedicated thoracic CT redemonstrated these lesions in addition to bilateral pleural effusions. High grade fever persisted despite appropriate antibiotic coverage with ertapenem and it was decided to aspirate the pleural effusions. Analysis of the aspirate was consistent with exudate; however cultures were sterile. Following the procedure the patient became afebrile and was subsequently switched to oral amoxicillin-clavulanate.
Discussion:
Fusobacterium is a component of normal orodental flora that is frequently implicated in periodontal infections. Fusobacterium bacteremia is unusual and often seen in the setting of Lemierre’s syndrome characterized by suppurative thrombophlebitis of the jugular vein and metastatic infection. Common sites of septic emboli include the lung and pleural space producing lung abscesses and empyema respectively. Metastatic infection can also occur at other sites, leading to empyema, septic arthritis, and/or osteomyelitis. When detected, Fusobacterium bacteremia should prompt a careful search for the source as well as metastatic infections that can overwhelm the clinical picture as was seen in this instance. Beta-lactamase production has been reported among F necrophorum and antibiotic regimens should be designed accordingly with inclusion of either a beta-lactamase inhibitor or use of a carbapenem.
Conclusions:
This case report highlights the severe complications that can arise from a seemingly innocuous dental infection. Fluid aspiration should be attempted in all patients with pleural effusions who remain febrile despite suitable antibiotic therapy.