692: Septic Shock From Sore Throat? Presentation of Streptococcus anginosus Shock and Lemierre Syndrome

Abstract

INTRODUCTION: Lemierre syndrome is septic thrombophlebitis of internal jugular vein caused by oropharyngeal or head and neck infections The main causative organism is Fusobacterium necrophorum but rarely other organisms such as Staphylococcus aureus, E coli, streptococci, staphylococci, Klebsiella etc can cause the syndrome as well Members of the Streptococcus Anginosus group are rare causes of Lemierre syndrome with very few pediatric case reports in the literature METHODS: A previously healthy 15-year-old female presented with four days of fever, throat pain, abdominal pain and persistent vomiting and was admitted with septic shock requiring extensive fluid resuscitation and vasopressor support Initial labs included WBC 15 2 x 10 9/ L, CRP 34 9 mg/dL, ESR 78 mm/Hr Review of systems was negative for tampon use Rapid streptococcus probe test, respiratory viral panel, and SARS CoV-2 tests were all negative Clindamycin was added to empiric coverage with concern for toxic shock syndrome Within 24 hours of hospitalization, she developed ARDS requiring non-invasive positive pressure ventilation She continued to complain of worsening throat pain and headache CT scan of the neck revealed extensive thrombosis of the left internal jugular and initial blood culture grew Streptococcus constellatus, a member of the S Anginosus group Antibiotic coverage was switched to piperacillin-tazobactam to cover anaerobic organisms such as Fusobacterium as well as Streptococcus Anginosis Enoxaparin was started Lupus antibodies were transiently positive secondary to infection Following discharge, she received intravenous ceftriaxone via PICC line and oral metronidazole for 3 weeks and then oral levofloxacin and metronidazole for 2 weeks She was followed up regularly to assure clearance of septic thrombi from internal jugular vein after 6 weeks of antithrombotic therapy RESULTS: Lemierre syndrome should be considered a diagnosis for an adolescent with throat pain presenting with shock