Transcript Case Presentation

CASE PRESENTATION
Myra Lalas
HPI






16 yo male previously healthy who presented to the
Peds ED with:
sore throat and dysphagia x 4 days
Fever x 3 days (Tm = 105.3)
L neck and shoulder pain x 1 day
Headache x 1 day
Decreased PO









NBNB emesis x 1 yesterday
Diarrhea 4 days ago
Hematuria
No abdominal pain
No rhinorrhea
No cough
No rash
No sick contacts
No recent travel
PMH



None
No known allergies
Shots UTD
FMH

noncontributory
HEADSS




Lives with both parents and brother.
In 11th grade
Denies EtOH, nicotine, illicit drugs
Sexually active, uses condoms, 3 SP’s, (-) STD history
PE





VS T 100 BP 110/54 P 128 R 28 99%RA
GEN Uncomfortable, has difficulty moving due to
neck pain
HEENT NCAT, PERLLA, EOMI, MMM, OP clear, (+) Lsided tenderness to palpation, with some erythema
CHEST (+) rhonchi on R base
HEART N S1/S2, no murmurs



ABD soft, (+) BS, NT/ND, no HSM, no CVA
tenderness
EXT FEP, CRT < 2 s
NECK no Kernig’s, no Brudzinski’s
LABS








CBC
Blood Culture
CMP
D dimer
Fibrinogen
Coags
UA
Urine culture
Imaging




CXR- normal
CT Scan Chest: multiple lesions in b/l lung fields
CT abd/pelvis for hematuria: (+) nodules at b/l
lung fields
Neck US: b/l cervical LAD; (+) L IJV thrombus in
superior cervical portion into tributary
ER Course



BP dropped to 90/40- received NS bolus x 2
Peds ID consulted: thrombus likely infected and
spreading septic emboli to lungs; showing signs of
sepsis and DIC w/c may explain ARF and crea of
2.1
Start Vanco, Flagyl, and Ceftriaxone
Differentials?








Cat scratch disease
Candidiasis
Cellulitis
Endocarditis
Mastoiditis
Pharyngitis
Sinusitis
Superficial thrombophlebitis
Lemierre’s Disease


Jugular vein thrombophlebitis
Usual sources of infection:
 Tonsil
 Pharynx/
URTI
 Chest/ LRTI
 Middle ear/ mastoid
 Larynx
 Dental
 Paranasal sinus
Usual First Clinical Symptoms








Sore throat
Neck mass
Neck pain
Bone/ joint pain
Otalgia and/or otorrhea
Dental pain
Orbital pain
GI symptoms
Microbiology






Fusobacterium necrophorum
Other Fusobacterium sp.
Eikenella corrodens
Porphyromonas asaccharolytica
Streptococci including S. pyogenes
Bacteroides
Pathophysiology



Production of bacterial toxins (e.g., LPS) leads to
secretion of cytokines by leukocytes- SEPTIC
SYMPTOMS
Production of hemagglutinin- causes platelet
aggregation that can lead to DIC and
thrombocytopenia
Inflammation and septic thrombophlebitis gives rise
to distant emboli that usu. migrate to pulmonary
capillaries
Sites of Septic Mets


Lungs
Joints
 Knee
 Hip
 Sternoclavicular
 Shoulder
 elbow
joint
Diagnostics



High resolution CT Scan with contrast- probably the
most useful investigation for jugular or vena caval
suppurative thrombophlebitis and may demonstrate
soft tissue swelling and filling defects or thrombus
Venography
US- not useful in regions deep to the clavicle or
mandible
Treatment




removal of the initiating focus of infection (eg,
intravenous catheter)
prompt initiation of high dose intravenous antibiotics
surgical consultation and intervention
consideration of anticoagulation.
Antibiotics



a beta-lactamase resistant beta-lactam antibiotic is
recommended for the treatment of this infection:
Ticarcillin-clavulanate (3.1 g IV every four hours) or
imipenem (500 mg to 1 g every six hours).
The duration of therapy generally is for at least
four weeks or until pulmonary abscesses have
resolved by CT scan.
Surgery


Surgical exploration, with ligation or excision of the
internal jugular vein is occasionally required.
Surgical drainage of pulmonary abscesses or
empyema may be necessary.
Anticoagulation

Remains controversial as its use has not been
properly assessed due to the low incidence of the
disease
References


Karkos et al. Lemierre’s syndrome: a systematic
review. The Laryngoscope. 2009: The American
Laryngological, Rhinological and Otological Society,
Inc; pp. 1-8.
www.uptodate.com