AN ATYPICAL PRESENTATION OF LEMIERRE'S SYNDROME

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lemierre's syndrome involves recent oropharyngeal infection, clinical or radiological evidence of internal jugular vein thrombosis, and isolation of anaerobic pathogens, most commonly Fusobacterium necrophorum. We present an atypical presentation of Lemierre's syndrome. CASE PRESENTATION: A 28-year-old male with a history of left second metacarpal neck fracture status post open internal reduction and pin removal one month prior presented with malaise, chills, and hand pain. His review of systems were significant for fever, headache, sore throat, productive cough, pleuritic chest pain, and dyspnea. He was febrile, tachycardic, and hypoxic. Examination revealed edema and erythema of the left hand and wrist, tenderness to palpation, and a bounding radial pulse. Laboratory investigations revealed a white cell count of 7.7 Thou/mcL, C-reactive protein 28.65 mg/dL, lactic acid 5.1 mmol/L, and procalcitonin 74.64 ng/mL. Chest X-ray showed bibasilar infiltrates. Computed tomography (CT) of the left hand showed soft tissue edema and emphysema of the wrist, hand, and forearm. He was diagnosed with sepsis due to left upper extremity necrotizing fasciitis and underwent fasciotomy with debridement. Wound cultures had no growth. Blood cultures grew Fusobacterium necrophorum. CT angiography of the pulmonary arteries revealed septic emboli. Venous duplex of the upper extremities revealed a chronic complete thrombus of the right internal jugular vein. Transthoracic echocardiogram showed no evidence of endocarditis. The diagnosis of Lemierre's Syndrome was made. The patient was discharged on enoxaparin and metronidazole for treatment. DISCUSSION: Lemierre's syndrome was first characterized by Dr. Andre Lemierre in 1936.1 The incidence decreased significantly with widespread usage of beta-lactam antibiotics in pharyngiitis.1 Due to antibiotic stewardship, the incidence has increased.1 Our patient presented with fever, left hand pain, and concern for necrotizing fasciitis with low suspicion of Lemierre's syndrome. Upon review, he did have elements consistent with the typical presentation of Lemierre's. Fever and sore throat are predominant symptoms; late sequelae involve septic emboli to the lungs resulting in chest pain and shortness of breath.3 Despite the increase in incidence of Lemierre's syndrome since physicians began practicing antibiotic stewardship, it is still rare. It is important to keep this as a differential as the mortality is around 5% if left untreated.1 CONCLUSIONS: The incidence of Lemierre's Syndrome continues to rise with the practice of antibiotic stewardship. It is crucial to consider this potentially fatal diagnosis when the clinical picture is consistent with Lemierre's syndrome. REFERENCE #1: Karkos PD, Asrani S, Karkos CD, et al. Lemierre's syndrome: A systematic review. Laryngoscope. 2009;119(8):1552-1559. doi:10.1002/lary.20542 REFERENCE #2: Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre's syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect. 2020;53(4):513-517. doi:10.1016/j.jmii.2020.03.027 REFERENCE #3: Olivier JB, Al-Hourani K, Bolland B. Lemierre's syndrome; a rare cause of septic arthritis. BMJ Case Rep. 2017;2017:bcr2017220110. Published 2017 May 12. doi:10.1136/bcr-2017-220110 DISCLOSURES: No relevant relationships by Mikhail de Jesus, source=Web Response no disclosure on file for Jason Jacob; No relevant relationships by Rafae Shaikh, source=Web Response No relevant relationships by Asiya Tafader, source=Web Response