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A5220 - Lemierre’s Syndrome with Negative Blood Cultures and Internal Carotid Artery Involvement
Author Block: U. Trytko1, E. K. Moy2; 1Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ, United States, 2University Medical Center of Princeton, Plainsboro, NJ, United States.
Lemierre’s Syndrome, also known as jugular vein suppurative thrombophlebitis, occurs when carotid sheath vessels are inflamed due to an infection. Most cases described in literature occur after an oropharyngeal infection and are associated with bacteremia and sepsis due to an anaerobic organism. Diagnosis is often confirmed by imaging of the head and neck. We present a unique case of Lemierre’s Syndome, with negative blood cultures and presenting as acute respiratory failure. A 61 year old male with a past medical history of squamous cell carcinoma of the head and neck status post chemotherapy and radiation complicated by trismus who presented with shortness of breath and stridor. Two weeks prior to admission, a position emission tomography scan showed a lukewarm hot spot in patient’s oropharynx suggesting recurrence of the head and neck cancer. On physical exam, blood pressure was 160/109 but dropped to 87/70, heart rate 151 beats per minute, temperature 101.8 degrees Fahrenheit, respiratory rate 46 breaths per minute, oxygen saturation 100% on BIPAP. Physical exam was significant for severe trismus, swelling on the right side of the neck, and tachycardia. Oropharynx was not able to be examined due to trismus. Laboratory studies were significant for white blood cell count of 20.7 k/cumm, platelet count of 580 k/cumm, CO2 of 30 mmol/L, lactate of 1.6 mmol/L. Chest xray showed a density at the medial left lung base and a soft tissue fullness at the base of the epiglottis causing upper airway obstruction. A computerized tomography scan of the neck showed mass effect with probable abscess in the left pharynx, severe stenosis of the left internal carotid artery with probable dissection, and non-visualization of the left internal jugular vein suggesting stenosis or thrombosis. Blood cultures showed no growth at 5 days. Patient was treated for acute respiratory failure secondary to central airway obstruction. He was placed on BIPAP, and started on racemic epinephrine and methylprednisolone after which his symptoms improved. A major concern on admission was that intubation would not be possible due to significant trismus. Lemierre’s Syndrome is becoming increasingly less common in setting of wide spread use of antibiotics. As per literature, it should be suspected in a patient with antecedent pharyngitis as well as positive blood cultures and persistent fevers despite antibiotic treatment. However, it is important to consider the diagnosis despite blood cultures being negative and when a patient presents with acute respiratory failure.