A life-threatening sore throat

Abstract

A 21-year-old man presented in August, 2003, with a 1-week history of a sore throat, nausea and vomiting, and abdominal pain. On admission he was febrile and dehydrated with signs of a chest infection and severe sepsis. He also had a tender, swollen neck but no signs of tonsillitis or abscesses. Blood tests showed thrombocytopaenia; platelets 30×109/L, white cell count; 6·6×109/L, C-reactive protein; 326 mg/L, urea; 19·8 mmol/L and creatinine; 199 mmol/L. We gave the patient oxygen, intravenous fluids, ceftriaxone and clarithromycin. The next day the patient's condition deteriorated and the microbiologist advised us to change the antiobiotics to gentamicin and levofloxacin. Later that day, anaerobic blood cultures grew gram negative bacteria, and the microbiologist advised us to add piperacillin/tazobactam and metronidazole to cover Pseudomonas and Bacterioides. We stopped ceftriaxone and gentamicin. After 48 h, the patient needed ventilation for worsening respiratory failure. CT of his neck showed oropharangeal oedema, and parapharangeal oedema on the right. On day 4 the bacteria in culture were identified as Fusobacterium necrophorum and Peptostreptococcus magnus. We diagnosed Lemierre's syndrome and as the fusobacterium isolate was sensitive to penicillin, we replaced levofloxacin with benzylpenicillin. We reviewed the original CT and noticed thrombus in the right internal jugular vein. CT of the chest showed septic emboli and multiple cavitating lesions (figure). The patient was ventilated for 18 days, required a tracheostomy, developed bilateral pleural effusions and a left-sided pneumothorax. He eventually made a full recovery and was discharged after 5 weeks in hospital. When last seen in February, 2004, he had returned to work as an auto mechanic, but was still taking warfarin and receiving physiotherapy.