Home
|
Inbox
|
Search
|
View Abstract
Adding Insult to Injury: Complicated Parapneumonic Effusion in a Patient with Lemierre's Syndrome
Description
.abstract img { width:300px !important; height:auto; display:block; text-align:center; margin-top:10px } .abstract { overflow-x:scroll } .abstract table { width:100%; display:block; border:hidden; border-collapse: collapse; margin-top:10px } .abstract td, th { border-top: 1px solid #ddd; padding: 4px 8px; } .abstract tbody tr:nth-child(even) td { background-color: #efefef; } .abstract a { overflow-wrap: break-word; word-wrap: break-word; }
A5325 - Adding Insult to Injury: Complicated Parapneumonic Effusion in a Patient with Lemierre's Syndrome
Author Block: A. Ajayi1, D. Kirakossian1, J. Murphy1, H. Nasiri2; 1Internal Medicine, Kaiser Permanente Santa Clara, Santa Clara, CA, United States, 2Critical Care Medicine, Kaiser Permanente Medical Center - Santa Clara, Santa Clara, CA, United States.
Introduction
Lemierre’s Syndrome is a rare infection that begins in the oropharynx with subsequent internal jugular (IJ) vein thrombophlebitis proceeded by septic emboli, particularly to the lungs. It typically affects previously healthy young individuals between the ages of 16 and 30 years. It is usually caused by anaerobic bacteria, commonly Fusobacterium necrophorum and nucleotum. It can be life threatening if not promptly treated.
Case Report
A 20-year-old man with past medical history of allergic rhinitis and remote tuberculosis presented to clinic with 3 weeks of cough, myalgia, fever, chills and 2 days of diffuse rash. Viral exanthem was suspected and routine supportive care was recommended. Three days later, he reported sore throat but resolution of cough. A strep test resulted positive and he was treated with azithromycin. He improved, but then returned two weeks later with recurrent symptoms. Chest x-ray (CXR) was unremarkable. He was treated with penicillin for possible streptococcal pharyngitis.
Four days later, he presented to the emergency room with new severe mid-thoracic back pain and night sweats. Exam revealed fever, tachycardia, cobble-stoning in the oropharynx, tender anterior cervical lymphadenopathy, and negative Kernig’s/Brudzinski’s signs. Labs values were notable for leukocytosis, bandemia, transaminitis and elevated inflammatory markers. CXR showed subtle early infiltrate in right midlung. Treatment was started for community-acquired pneumonia. Neck CT confirmed thrombus in left IJ vein. Chest CT showed right loculated pleural effusion and compressive atelectasis. Antibiotics were escalated.
His hospital course was notable for acute hypoxemic respiratory failure due to worsening lung consolidations and parapneumonic effusion. He required non-invasive mechanical ventilation and right chest tube placement with tissue plasminogen activator (tPA) and DNase therapy. Blood cultures grew Fusobacterium nucleotum sensitive to Ertapenem for which he completed a 6-week course. Repeat chest CT showed near complete resolution of pleural effusion. He was discharged home with infectious disease follow-up.
Discussion
Lemierre’s syndrome should be suspected in young patients with a course of pharyngitis that progresses despite treatment. Diagnosis is confirmed by recent history of pharyngitis, presence of IJ vein thrombophlebitis and/or positive blood cultures with growth of anaerobic bacteria and evidence of septic emboli. Cornerstone of treatment is a long course of antibiotics. Other treatment modalities include anticoagulation, drainage of abscesses, chest tube placement, video-assisted thoracoscopic surgery, intrapleural tPA/DNase. Our patient’s case highlights that while antibiotics are absolutely necessary, this alone may be insufficient and intrapleural lytic therapy should be considered in patients with parapneumonic effusions
Author Block: A. Ajayi1, D. Kirakossian1, J. Murphy1, H. Nasiri2; 1Internal Medicine, Kaiser Permanente Santa Clara, Santa Clara, CA, United States, 2Critical Care Medicine, Kaiser Permanente Medical Center - Santa Clara, Santa Clara, CA, United States.
Introduction
Lemierre’s Syndrome is a rare infection that begins in the oropharynx with subsequent internal jugular (IJ) vein thrombophlebitis proceeded by septic emboli, particularly to the lungs. It typically affects previously healthy young individuals between the ages of 16 and 30 years. It is usually caused by anaerobic bacteria, commonly Fusobacterium necrophorum and nucleotum. It can be life threatening if not promptly treated.
Case Report
A 20-year-old man with past medical history of allergic rhinitis and remote tuberculosis presented to clinic with 3 weeks of cough, myalgia, fever, chills and 2 days of diffuse rash. Viral exanthem was suspected and routine supportive care was recommended. Three days later, he reported sore throat but resolution of cough. A strep test resulted positive and he was treated with azithromycin. He improved, but then returned two weeks later with recurrent symptoms. Chest x-ray (CXR) was unremarkable. He was treated with penicillin for possible streptococcal pharyngitis.
Four days later, he presented to the emergency room with new severe mid-thoracic back pain and night sweats. Exam revealed fever, tachycardia, cobble-stoning in the oropharynx, tender anterior cervical lymphadenopathy, and negative Kernig’s/Brudzinski’s signs. Labs values were notable for leukocytosis, bandemia, transaminitis and elevated inflammatory markers. CXR showed subtle early infiltrate in right midlung. Treatment was started for community-acquired pneumonia. Neck CT confirmed thrombus in left IJ vein. Chest CT showed right loculated pleural effusion and compressive atelectasis. Antibiotics were escalated.
His hospital course was notable for acute hypoxemic respiratory failure due to worsening lung consolidations and parapneumonic effusion. He required non-invasive mechanical ventilation and right chest tube placement with tissue plasminogen activator (tPA) and DNase therapy. Blood cultures grew Fusobacterium nucleotum sensitive to Ertapenem for which he completed a 6-week course. Repeat chest CT showed near complete resolution of pleural effusion. He was discharged home with infectious disease follow-up.
Discussion
Lemierre’s syndrome should be suspected in young patients with a course of pharyngitis that progresses despite treatment. Diagnosis is confirmed by recent history of pharyngitis, presence of IJ vein thrombophlebitis and/or positive blood cultures with growth of anaerobic bacteria and evidence of septic emboli. Cornerstone of treatment is a long course of antibiotics. Other treatment modalities include anticoagulation, drainage of abscesses, chest tube placement, video-assisted thoracoscopic surgery, intrapleural tPA/DNase. Our patient’s case highlights that while antibiotics are absolutely necessary, this alone may be insufficient and intrapleural lytic therapy should be considered in patients with parapneumonic effusions
|
Home
|
Inbox
|
Search
|