Not Forgotten by Novel Disease: COVID-19 Complicated by Lemierre’s Syndrome

Abstract

Introduction: Lemierre's syndrome is an extremely rare disease that generally occurs in young, healthy adults and is characterized by oropharyngeal infection followed by septic thrombophlebitis of the internal jugular vein. We present a case of COVID-19 infection complicated by acute mastoiditis with concomitant Lemierre's syndrome. Case Presentation: A 57-year-old male with obesity and asthma presented with worsening dyspnea after diagnosis of COVID-19 three days prior. The patient was febrile to 101 degrees Fahrenheit and hypoxemic requiring 15 liters supplemental oxygen. CT chest showed severe multifocal bilateral pulmonary opacities and initial blood cultures were negative. He received dexamethasone, remdesivir, and convalescent plasma but clinical status deteriorated with progression of respiratory and renal failure. The patient was eventually intubated and a left internal jugular central venous catheter was placed for renal replacement therapy. Hospital course was further complicated by new onset atrial fibrillation with RVR, for which amiodarone and heparin infusions were started. Four days later, the patient developed intermittent fevers and was found to have Fusobacterium nucleatum bacteremia. Doppler ultrasound showed thrombosis of the left internal jugular vein consistent with Lemierre's syndrome. Physical exam did not exhibit neck edema, induration or dental infection, but CT head and chest revealed acute bilateral mastoiditis and new right upper lobe abscess. Despite removal of internal jugular venous catheter, continued anticoagulation, and initiation of broad spectrum antibiotics, the patient developed worsening multiorgan failure and septic shock requiring vasopressors. He ultimately underwent PEA arrest and did not survive resuscitation. Discussion: Lemierre's syndrome is a rare condition with an estimated worldwide incidence of one in 1 million and a high mortality between 5% to 18%. The most common pathogen is Fusobacterium necrophorum. Moreover, our patient had elevated risk of thrombosis from COVID-19 and a recently placed central venous catheter. As providers increasingly care for patients with COVID-19, early recognition and management of this rare complication is paramount to reduce mortality. Fusobacterium bacteremia should lead to a high index of suspicion for timely diagnosis and treatment of Lemierre's syndrome.