ATYPICAL PRESENTATION OF LEMIERRE'S SYNDROME WITH ISOLATED INVOLVEMENT OF THE EXTERNAL JUGULAR VEIN

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lemierre’s syndrome is a life-threatening complication of pharyngitis leading to internal jugular vein (IJV) thrombophlebitis with pulmonary septic embolisation. Isolated external jugular vein (EJV) thrombophlebitis is rare. CASE PRESENTATION: A 35-year-old woman presented with one day of acute pleuritic chest pain. She had fever, chills, throat pain, dysphagia, malaise, and headache for 2 weeks. On presentation, she had trismus, extensive tender cervical lymphadenopathy with swelling on the left side of the neck, erythematous posterior pharynx and left enlarged erythematous tonsillar pillars without exudates. Blood showed leucocytosis with neutrophil predominance, elevated D-dimer, CRP, elevated bilirubin with normal liver enzymes, low platelets, low albumin, and blood culture revealed Fusobacterium necrophorum. Contrast CT scan soft tissue of the neck showed left tonsillar pillar enlargement with micro-abscesses and extension of inflammation into the left submandibular, parotid, and cervical space with thrombosis of the left EJV. Extension of inflammation into the retro-pharyngeal space was noted. CT Angiogram of Chest revealed bilateral peripheral opacities with cavitation in the right upper lobe and left lower lobe consistent with septic emboli. IJV revealed no thrombosis. A diagnosis of Lemierre’s syndrome was made. The patient improved on antibiotic therapy. DISCUSSION: Lemierre’s syndrome is a rare potentially lethal complication of oropharyngeal infection occurring mainly in young adults characterised by septic thrombophlebitis of the IJV with embolisation to lungs. It is rare (3.6 cases/million/year) with a mortality rate of >15%. 1,2. The common causative organisms are anaerobic gram-negative bacilli from the genus Fusobacterium mainly F. necrophorum.3 The oropharyngeal infection spreads to IJV from local oropharyngeal veins. Lymphatic spread and direct extension of infection also occur. However, in some patients, the venous drainage allows direct propagation of thrombophlebitis into the EJV.3 Patients present with fever, sore throat, neck swelling, pleuritic chest pain with cervical lymphadenopathy. Leucocytosis, elevated ESR, CRP, bilirubin and thrombophilia are seen. CT scan of the soft tissue of the neck and chest with contrast is required for diagnosis. CONCLUSIONS: In patients with severe pharyngitis and pulmonary septic emboli Lemierre’s syndrome must be suspected and the venous system of the neck should be closely visualised for evidence of thrombophlebitis of both IJV and EJV. Reference #1: Nall RW. Sore Throat. In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 4e New York, NY: McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2715§ionid=228250877. Accessed May 28, 2020.2. Reference #2: Barlam TF, Kasper DL. Approach to the Acutely Ill Infected Febrile Patient. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e New York, NY: McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=183880456. Accessed May 28, 2020 Reference #3: Format:Reicher J, Brooke S, Arnold D, Counter P, Abdelgalil A. An unusual case of cavitating pulmonary nodules: Lemierre's syndrome with isolated involvement of the external jugular vein. BJR Case Rep. 2018;4(3):20170093. Published 2018 Feb 22. doi:10.1259/bjrcr.20170093 DISCLOSURES: No relevant relationships by Anomadarshi Barua, source=Web Response No relevant relationships by padmanabhan krishnan, source=Web Response No relevant relationships by Litty Mathews, source=Web Response No relevant relationships by Qasim Sheikh, source=Web Response No relevant relationships by Sarita Singh, source=Web Response