Lemierre syndrome: a case of pharyngotonsilar abscess leading to pulmonary septic emboli

SESSION TITLE: Chest Infections Case Report Posters 31 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Lemierre syndrome refers to septic thrombophlebitis of the internal jugular vein (IJV). The condition typically involves anaerobic organisms causing a primary oropharyngeal infection leading to local extension to the internal jugular vein (IJV). This results in phlebitis with infected thrombus and persistent bacteremia, ultimately leading to septic emboli frequently involving the lungs, joints, and brain. CASE PRESENTATION: A 21-year-old man presented with dyspnea and chest pain on deep inspiration for four days. On arrival at the hospital, he was febrile, tachycardic, and hypoxemic, necessitating the utilization of high-flow nasal cannula and admission to the critical care unit. He denied significant exposures or illicit drug use. CT of the chest demonstrated multifocal nodular opacities and extensive left lower lobe consolidation with cavitation with initial concern for septic emboli. Blood cultures resulted positive for Fusobacterium with a transthoracic echocardiogram negative for vegetation. Upon examination, he was noted to have pharyngeal tenderness; therefore, a neck CT was obtained. This reported a 1cm right peritonsillar abscess and signs of phlebitis in the left IJV with a non-occlusive filling defect. His antibiotics were narrowed to IV Metronidazole based on sensitivities, exhibiting significant improvement with resolution of hypoxemia and fever. He was eventually discharged with plans to complete four weeks of oral antibiotic coverage. DISCUSSION: Lemierre's syndrome is commonly described among young adults and can potentially be fatal, with an annual incidence of 3–6 cases per million in the general population. Affected individuals often present with a classic finding of pharyngitis and neck tenderness associated with a pharyngeal abscess that often requires drainage. Symptoms, however, can be subtle and present with other primary foci of infection. The diagnosis of IJV thrombophlebitis can be aided by neck ultrasonography or CT of the neck. Infectious pathogens from oral flora are usually involved, with Fusobacterium species being common. Fusobacterium can take more than five days to grow on cultures, delaying appropriate antibiotic therapy. Therefore, initial empiric treatment should include coverage against Fusobacterium and oral streptococci. Hematogenous spread can occur, causing lung involvement, epidural and brain abscesses, septic arthritis, and ultimately death due to septic shock if left untreated. The usual duration of treatment is typically four weeks but is typically guided by involved sites. CONCLUSIONS: Recognition of Lemierre's syndrome requires a high index of suspicion in the appropriate clinical setting. Therefore, management includes a multidisciplinary team approach, with early empiric antibiotic treatment against common oral pathogens and abscess drainage when appropriate. In addition, complications from hematogenous spread should be evaluated. REFERENCE #1: Lee, W., Jean, S., Chen, F., Hsieh, S., & Hsueh, P. (2020). Lemierre's syndrome: A forgotten and re-emerging infection. Journal of Microbiology, Immunology and Infection, 53(4), 513-517. REFERENCE #2: Hagelskjaer Kristensen L, Prag J. Lemierre's syndrome and other disseminated Fusobacterium necrophorum infections in Denmark: a prospective epidemiological and clinical survey. Eur J Clin Microbiol Infect Dis. 2008;27(9):779-789. REFERENCE #3: Karkos PD, Asrani S, Karkos CD, et al. Lemierre's syndrome: A systematic review. Laryngoscope. 2009;119(8):1552-1559. DISCLOSURES: No relevant relationships by Dorys Chavez Melendez No relevant relationships by Aakash Goyal No relevant relationships by Gustavo Adolfo Rodriguez Rivera No relevant relationships by Arnaldo Rodriguez-Rivera No relevant relationships by Kumar Sarvottam No relevant relationships by Sahar Sultan