Atypical Presentation of Lemierre’s Syndrome Causing Septic Shock and Acute Respiratory Distress Syndrome

Case Reports in Infectious Diseases, Jul 2018

Lemierre’s disease is a rare but life-threatening condition characterized by an oropharyngeal infection complicating with thrombophlebitis of the internal jugular vein and disseminated abscesses. We are presenting a case of a young female who initially presented with fevers, chills, sore throat, and swollen neck later developed progressively worsening shortness of breath along with sudden onset pleuritic chest pain. She then developed progressively worsening acute hypoxic respiratory failure requiring intubation and mechanical ventilation. Interval chest X-ray showed worsening bilateral effusions. She also developed septic shock requiring pressors. Blood culture showed Fusobacterium, and antibiotics were changed accordingly following which there was a clinical improvement. The diagnosis of Lemierre’s syndrome was then established based on her presenting age and bilateral pulmonary empyema in the setting of septicemia with Fusobacterium.

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Atypical Presentation of Lemierre’s Syndrome Causing Septic Shock and Acute Respiratory Distress Syndrome

Atypical Presentation of Lemierre’s Syndrome Causing Septic Shock and Acute Respiratory Distress Syndrome Divyesh Reddy Nemakayala, Manoj P Rai, Shilpa Kavuturu, and Supratik Rayamajhi Department of Medicine, Michigan State University, 804 Service Road, Room B301, East Lansing, MI 48824, USA Correspondence should be addressed to Manoj P Rai; [email protected] Received 26 February 2018; Accepted 30 May 2018; Published 2 July 2018 Academic Editor: Paola Di Carlo Copyright © 2018 Divyesh Reddy Nemakayala et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Lemierre’s disease is a rare but life-threatening condition characterized by an oropharyngeal infection complicating with thrombophlebitis of the internal jugular vein and disseminated abscesses. We are presenting a case of a young female who initially presented with fevers, chills, sore throat, and swollen neck later developed progressively worsening shortness of breath along with sudden onset pleuritic chest pain. She then developed progressively worsening acute hypoxic respiratory failure requiring intubation and mechanical ventilation. Interval chest X-ray showed worsening bilateral effusions. She also developed septic shock requiring pressors. Blood culture showed Fusobacterium, and antibiotics were changed accordingly following which there was a clinical improvement. The diagnosis of Lemierre’s syndrome was then established based on her presenting age and bilateral pulmonary empyema in the setting of septicemia with Fusobacterium. 1. Introduction Lemierre’s syndrome typically begins with an oropharyngeal infection. It invades the pharyngeal mucosa to cause septic thrombophlebitis of the internal jugular vein (IJV). Thrombophlebitis of the IJV then seeds to cause bacteremia and metastatic septic emboli. Fusobacterium most commonly causes Lemierre’s syndrome. Even though it was first reported by Courmont and Cade [1], a clear description was provided by André Lemierre in 1936 [1] and [2]. Here, we present an 18-year-old female who developed acute respiratory distress syndrome (ARDS) as a complication of Lemierre’s syndrome. 2. Case An 18-year-old female without significant past medical history initially presented to urgent care with complaints of a sore throat, swollen neck, fevers, and chills for 5 days. At the urgent care, the rapid strep test came back negative. She was then sent home on steroids and azithromycin. She presented to the emergency department two days later with progressively worsening shortness of breath along with sudden onset pleuritic chest pain. Review of systems was remarkable for shortness of breath and chest pain. Vitals showed temperature of 99 °F, blood pressure of 107/66 mm Hg, a pulse of 138/min, respiratory rate of 28/min, and SpO2 of 97%. Physical examination was remarkable for tenderness in the neck, pus formation on the tonsils, and decreased breath sounds. Labs were remarkable for severe thrombocytopenia, leukocytosis with left shift, granulated polymorphonuclear leukocytes (PMNs), and acute kidney injury (AKI). Initial chest X-ray showed bilateral pleural effusions (Figure 1). Computed tomography (CT) chest without contrast showed bilateral lung nodules and pleural effusions (Figure 2). Echocardiogram demonstrated small pleural effusion with normal ejection fraction. Bilateral neck ultrasound and computed tomography (CT) neck without contrast did not show jugular vein thrombophlebitis or peritonsillar abscess, although the study was limited due to insertion of bilateral internal jugular (IJ) catheter insertions. Blood cultures were obtained, intravenous fluids were given, and empiric antibiotic therapy was started with intravenous (IV) vancomycin, IV cefepime, and IV doxycycline. The patient became more hypoxic requiring intubation and mechanical ventilation and went into septic shock requiring pressors. An interval chest X-ray demonstrated worsening bilateral effusions (Figure 3). Her renal function deteriorated requiring continuous renal replacement therapy (CRRT). She then developed cardiac arrest due to pulseless electrical activity (PEA) following chest compressions, and there was a return of spontaneous circulation (ROSC). Blood culture grew Fusobacterium, and antibiotics were changed to IV meropenem. To drain the empyema, bilateral chest tubes were placed, the sample was cultured, and it was negative for bacterial growth. The patient also had a left-sided pneumothorax, and it was unsure if the cause was secondary to the underlying infection or iatrogenic. She was placed on acute respiratory distress syndrome (ARDS) net protocol following which there was an improvement, and she was eventually weaned off the ventilator. A repeat CT chest abdomen pelvis with contrast 5 days later was ordered which showed septic emboli in the lungs (...truncated)


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Divyesh Reddy Nemakayala, Manoj P Rai, Shilpa Kavuturu, Supratik Rayamajhi. Atypical Presentation of Lemierre’s Syndrome Causing Septic Shock and Acute Respiratory Distress Syndrome, Case Reports in Infectious Diseases, 2018, 2018, DOI: 10.1155/2018/5469053