An unusual case of cavitating pulmonary nodules: Lemierre's syndrome with isolated involvement of the external jugular vein.

John Reicher,Alaa Abdelgalil,Paul Counter,Dominic Arnold,Sam Brooke

doi:10.1259/bjrcr.20170093

Abstract

A 65-year-old female presented with symptoms of tonsillitis and sepsis. Despite initial treatment with i.v. fluid and antibiotics, her condition deteriorated and she became hypoxaemic. CT pulmonary angiography showed no filling defects in the pulmonary arteries, but there were multiple cavitating lung nodules, initially thought to represent metastases. A subsequent contrast-enhanced CT of the neck and thorax demonstrated thrombosis of the left external jugular vein (EJV), leading to a revised diagnosis of Lemierre’s syndrome (i.e. septic embolization from jugular thrombophlebitis). Noteworthy aspects of the case include the initial misdiagnosis of the cavitating lung nodules by the reporting radiologist and the isolated involvement of the EJV—Lemierre’s syndrome usually involves the internal jugular vein. The case highlights the importance of septic emboli in the differential diagnosis of cavitating lung nodules, and of assessment of the EJV as well as internal jugular vein in the context of oropharyngeal infection.

Highlights

The above case raises a number of important lessons for the general radiologist
The possibility of septic embolization from 5 of 7 birpublications.org/bjr isolated external jugular vein (EJV) thrombophlebitis serves as a reminder to examine closely the EJVs as well as the internal jugular veins (IJVs), in the context of oropharyngeal infection
On the original CT pulmonary angiogram, in which the neck vessels were not opacified, the only sign of EJV thrombosis was a single small locule of gas—this highlights the value of contrast-enhanced CT of the neck in complicated oropharyngeal infection

Summary

Case report

An unusual case of cavitating pulmonary nodules: Lemierre’s syndrome with isolated involvement of the external jugular vein. Multiple, peripherally located, ill-defined nodules with cavitation, peripheral enhancement and lower zone predilection.[3,4] While these characteristics may help distinguish septic emboli from other causes—for example, mycobacterial disease, which typically displays an apical predilection—there is considerable overlap in the radiological appearances of the above differential diagnoses.[2] While there have been studies demonstrating that wall thickness and enhancement characteristics of solitary pulmonary cavities can aid the distinction between benign and malignant disease,[5,6] it is unclear whether such rules can be reliably applied in the presence of multiple cavities Given these potential difficulties in reaching a diagnosis on radiological grounds alone, additional investigations such as percutaneous biopsy may be helpful, this may not be feasible,[7] especially in the context of small lesions in an acutely unwell patient. Today most patients given prompt antibiotic therapy make a good recovery.[23]

Conclusions

Learning Points