A RARE CASE OF LEMIERRE'S SYNDROME CAUSED BY PREVOTELLA BUCCAE

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Jugular vein septic thrombophlebitis, also known as Lemierre's Syndrome (LS), is an extremely rare complication that is secondary to an acute oropharyngeal infection with retropharyngeal extension and metastatic spread. The disease was first described in 1936 and the incidence of this condition is approximately 0.8 people per million per year with a high mortality rate close to 24%. The most commonly isolated pathogen is Fusobacterium necrophorum, a common oral flora. Management depends on the initial presentation, type of pathogen isolated, and proper selection of antibiotics. CASE PRESENTATION: 67-year-old man with past medical history of coronary artery disease, hypertension and diabetes mellitus presented to the emergency department with a one-week history of anorexia and dysphagia. Patient denied fever, chills or shortness of breath. Vital signs remarkable for tachycardia. Physical examination remarkable for pharyngeal erythema and palpable neck mass, no evidence of exudates, no palpable lymphadenopathy. Neck CT Scan with IV contrast remarkable for complex enhancing fluid collection with phlegmonous inflammatory changes involving the left parapharyngeal space, carotid space, jugular chain and posterior neck triangle space with infiltration into the left jugular vein with intraluminal thrombosis which likely represents superimposed septic thrombophlebitis. Chest CT Scan with IV Contrast remarkable for left lower lobe atelectasis, consolidation with empyema. Management included intravenous antibiotics and thoracenthesis for his left side empyema. Neck abscess was drained. Due to persistent empyema a left side thoracotomy and total decortication was performed, leading to resolution of empyema. Final blood and abscess culture were remarkable for Prevotella buccae, which supported the diagnosis of LS. His condition improved and he was discharged with proper antibiotic coverage and outpatient follow-up. DISCUSSION: LS is a rare condition associated with metastatic infection spreading. This syndrome can be associated with further complications, such as pleural effusions and/or empyema as seen with our patient. Early suspicion and recognition are important to prevent fatal complications and provide adequate antibiotic coverage early on during treatment. Most patients with LS present with a pharyngitis-like picture and pulmonary symptoms. Our patient presented with an unusual clinical presentation when compared to other reports of LS and abscess culture was positive to an uncommonly involved organism. CONCLUSIONS: We present an effective multidisciplinary approach to the treatment of LS with associated ipsilateral empyema. We encourage to have a high level of suspicion of this syndrome in patients presenting with neck abscess, even though, they present with minimal symptoms and with uncommon organisms. This will prevent deterioration of the condition and will permit adequate treatment. REFERENCE #1: Valley, Thomas Sebastian MD*; Sheshadri, Ajay MD†; Hoopman, Todd C. MD‡ A Young Man With Empyema, Infectious Diseases in Clinical Practice: November 2011 - Volume 19 - Issue 6 - p e31-e32 doi: 10.1097/IPC.0b013e31822e9be3 REFERENCE #2: Wani, P., Antony, N., Wardi, M., Rodriguez-Castro, C. E., & Teleb, M. (2016). The Forgotten One: Lemierre's Syndrome Due to Gram-Negative Rods Prevotella Bacteremia. The American journal of case reports, 17, 18–22. https://doi.org/10.12659/ajcr.895560 REFERENCE #3: Lemierre A. On certain septicemias due to anaerobic organisms. Lancet. 1936;227(5874):701–3. DISCLOSURES: No relevant relationships by Daniel Font-Rivera, source=Web Response No relevant relationships by Sandra Galarza-Vargas, source=Web Response No relevant relationships by Emanuel Mejias Lafontaine, source=Web Response No relevant relationships by Claudia Quiles, source=Web Response