CASE PRESENTATION

Myra Lalas

HPI

16 yo male previously healthy who presented to the Peds ED with:

sore throat and dysphagia x 4 days Fever x 3 days (Tm = 105.3) L neck and shoulder pain x 1 day Headache x 1 day Decreased PO

NBNB emesis x 1 yesterday Diarrhea 4 days ago Hematuria No abdominal pain No rhinorrhea No cough No rash No sick contacts No recent travel

PMH

None No known allergies Shots UTD

FMH

noncontributory

HEADSS

Lives with both parents and brother. In 11th grade Denies EtOH, nicotine, illicit drugs Sexually active, uses condoms, 3 SP’s,

(-) STD history

PE

VS T 100 BP 110/54 P 128 R 28 99%RA

GEN Uncomfortable, has difficulty moving due to neck pain

HEENT NCAT, PERLLA, EOMI, MMM, OP clear, (+) L-sided tenderness to palpation, with some erythema

CHEST (+) rhonchi on R base HEART N S1/S2, no murmurs

ABD soft, (+) BS, NT/ND, no HSM, no CVA tenderness

EXT FEP, CRT < 2 s NECK no Kernig’s, no Brudzinski’s

LABS

CBC Blood Culture CMP D dimer Fibrinogen Coags UA Urine culture

Imaging

CXR- normal CT Scan Chest: multiple lesions in b/l

lung fields CT abd/pelvis for hematuria: (+) nodules

at b/l lung fields Neck US: b/l cervical LAD; (+) L IJV

thrombus in superior cervical portion into tributary

ER Course

BP dropped to 90/40- received NS bolus x 2

Peds ID consulted: thrombus likely infected and spreading septic emboli to lungs; showing signs of sepsis and DIC w/c may explain ARF and crea of 2.1

Start Vanco, Flagyl, and Ceftriaxone

Differentials?

Cat scratch disease Candidiasis Cellulitis Endocarditis Mastoiditis Pharyngitis Sinusitis Superficial thrombophlebitis

Lemierre’s Disease

Jugular vein thrombophlebitis Usual sources of infection:

Tonsil Pharynx/ URTI Chest/ LRTI Middle ear/ mastoid Larynx Dental Paranasal sinus

Usual First Clinical Symptoms Sore throat Neck mass Neck pain Bone/ joint pain Otalgia and/or otorrhea Dental pain Orbital pain GI symptoms

Microbiology

Fusobacterium necrophorum Other Fusobacterium sp. Eikenella corrodens Porphyromonas asaccharolytica Streptococci including S. pyogenes Bacteroides

Pathophysiology

Production of bacterial toxins (e.g., LPS) leads to secretion of cytokines by leukocytes- SEPTIC SYMPTOMS

Production of hemagglutinin- causes platelet aggregation that can lead to DIC and thrombocytopenia

Inflammation and septic thrombophlebitis gives rise to distant emboli that usu. migrate to pulmonary capillaries

Sites of Septic Mets

Lungs Joints

Knee Hip Sternoclavicular joint Shoulder elbow

Diagnostics

High resolution CT Scan with contrast- probably the most useful investigation for jugular or vena caval suppurative thrombophlebitis and may demonstrate soft tissue swelling and filling defects or thrombus

Venography US- not useful in regions deep to the

clavicle or mandible

Treatment

removal of the initiating focus of infection (eg, intravenous catheter)

prompt initiation of high dose intravenous antibiotics

surgical consultation and intervention consideration of anticoagulation.

Antibiotics

a beta-lactamase resistant beta-lactam antibiotic is recommended for the treatment of this infection:

Ticarcillin-clavulanate (3.1 g IV every four hours) or imipenem (500 mg to 1 g every six hours).

The duration of therapy generally is for at least four weeks or until pulmonary abscesses have resolved by CT scan.

Surgery

Surgical exploration, with ligation or excision of the internal jugular vein is occasionally required.

Surgical drainage of pulmonary abscesses or empyema may be necessary.

Anticoagulation

Remains controversial as its use has not been properly assessed due to the low incidence of the disease

References

Karkos et al. Lemierre’s syndrome: a systematic review. The Laryngoscope. 2009: The American Laryngological, Rhinological and Otological Society, Inc; pp. 1-8.

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