LEMIERRE'S SYNDROME: A FORGOTTEN DISEASE

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 largely forgotten disease in the era of antibiotics, with an incidence of 1 in 1 million per year. It is characterized by thrombophlebitis of the internal jugular (IJ) vein and bacteraemia of oral cavity anaerobes, in a young otherwise healthy adult. It was highly prevalent and often fatal prior to the introduction of antibiotics; however cases have since declined significantly, with a recent resurgence (1). CASE PRESENTATION: A 21-year-old female with no previous history presented with high grade fevers and progressive shortness of breath for 2 days. She reported a recent sore throat that failed to improve with oral Azithromycin. She denied any intravenous (IV) drug use or recent dental work. She was febrile at 103 F, with a HR: 128bpm, RR: 28 bpm & oxygen saturation: 86% on room air, requiring supplemental oxygen. Oropharyngeal exam was normal with a central uvula without any erythema, tonsillar exudates, or palpable cervical adenopathy. Labs were normal except for a leucocytosis of 13 k/mm3 and thrombocytopenia of 31 k/mm3. CT chest showed bilateral lung nodules with basilar, sub-pleural predominance & early cavitation consistent with septic emboli (Fig 1). CT neck showed a venous thrombus extending from the right palatine tonsillar vein into the right IJ vein, consistent with Lemierre's syndrome (Fig 2). Blood cultures grew Prevotella intermedia after 4 days of inoculation. She was started on broad spectrum antibiotics with de-escalation to oral amoxicillin/clavulanic acid and metronidazole for 6 weeks. Therapeutic anticoagulation was stopped after development of a haemothorax. DISCUSSION: Lemierre's syndrome is a triad of oropharyngeal infection with bacteremia, thrombophlebitis of IJ vein and distant metastatic abscesses, typically preceded by a sore throat which results in deep tissue invasion by highly thrombogenic oral anaerobes. The most frequent metastatic site is the lungs, but any organ may be involved (2). Most common pathogen responsible is Fusobacterium, an obligate anaerobic, gram-negative bacilli, but very limited literature is published regarding Provetella spec. associated Lemierre's syndrome (2). Incidence has significantly declined after the introduction of Penicillin, however, there has been a resurge, presumably due to a trend against prescribing antibiotics for sore throat (2-3). Diagnosis is usually clinical with supporting radiological evidence and growth of a typical causative organism, usually from blood. It is often mistakenly diagnosed as primary bacteremia from an infected organ or tonsillitis. Treatment consists of prolonged antibiotics and management of its complications. CONCLUSIONS: Lemierre's syndrome should be considered in any patient with unrelenting sore throat and anaerobic bacteremia. Prompt initiation of targeted antibiotics would prevent metastatic complications and thus reduce overall healthcare costs. Reference #1: Bilateral Lemierre's syndrome: a case report and literature review. Moore BA Et al. Ear Nose Throat J. 2002 Apr;81(4):234-6, 238-40, 242 passim. Reference #2: Lemierre’s syndrome: forgotten, but not absent. Bahall M, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221203 Reference #3: Lemierre’s syndrome: current perspectives on diagnosis and management. Katrine M Johannesen et al. Infection and Drug Resistance 2016:9 221–227 DISCLOSURES: No relevant relationships by Nelson Agudelo Higuita, source=Web Response No relevant relationships by Maham Khan, source=Web Response No relevant relationships by Miranda McGhee, source=Web Response No relevant relationships by Aejaz Ul Haq, source=Web Response