An Extensive Portal Venous Thrombosis in a Patient with a Pancreatic Abscess - A Lemierreʼs Syndrome Variant?

Abstract

Purpose: Lemierre's Syndrome, otherwise referred to human necrobacillosis or post-anginal sepsis, is a disease usually associated with the occurrence of a pharyngitis followed by migration of anerobes (most frequently Fusobacterium) to the internal jugular vein, forming a septic thrombus. These spread and form abscesses in distal organs, such as the lungs or liver. There has recently been an advent of atypical cases of Lemierre's Disease, referred to as variant cases, characterized by thrombus formation or thrombophlebitis in concert with abscesses, but in the absence of a clinical pharyngitis or Fusobacterial etiology. Lemierre's Syndrome was once considered a forgotten disease; however with the advent of antibiotic resistance, there has been a resurgence of this disease entity. This case pertains to a patient with history of aortic endograft placement who presented to the hospital with abdominal pain. A CT scan showed a pancreatic head mass and questionable liver abscess, in addition to a portal vein thrombus. A CT guided fine needle aspiration of the pancreatic head mass yielded Fusobacterium; the diagnosis of variant Lemierre's Syndrome was rendered. Course: Patient is a 62 year old man with a medical history of alcoholism and abdominal aortic aneurysm and endograft repair in 1995 who presented to an outside hospital with epigastric pain, weight loss of 40 pounds in 6 months, and fever. The patient's total bilirubin on admission was 2.4 mg/dL and his white blood cell count was 31.3 k/μL. An abdominal CT scan showed a pancreatic head mass as well as questionable liver lesions and a portal vein thrombus. The patient was started on Metronidazole and Levofloxacin. A CT guided FNA produced fluid, positive for Fusobacterium. Patient was transferred, where his antibiotics were augmented to include Pipercillin/Tazobactam. An MRI was done which showed changes in the liver consistent with ischemia related to septic thrombophlebitis - additionally there was some concern for aortic graft infection. A CT angiogram of the abdomen corroborated these findings and showed a possible duodenal diverticulum versus diverticular perforation. Push enteroscopy was considered, but with the patient's poor respiratory status, this pursuit was abolished. In the absence of peritoneal signs on abdominal exam or blood in the patient's stool, conservative management was chosen. Currently, the patient is doing well on appropriate antibiotic therapy. Discussion: In those individuals with cystic pancreatic lesions and in the absence of other diseases such as cancer to explain the patient's presentation, Fusobacterium infections should be given consideration.