Transcript CASE CONFERENCE

Au Manongas, MD
PGY-2
December 9, 2009
 16
y/o male with chest pain
 Patient
presented to PMD ten days ago for
sore throat and dysphagia. Strep test done
was negative and he was discharged home.
His symptoms continued and became
associated with fever, neck pain and
swelling and so he went back to PMD after
three days and was placed on
Azithromycin. One day prior, he developed
chills, 2 episodes of NBNB vomiting,
progressive shortness of breathing and
pleuritic chest pain.
 Past
Medical History: Unremarkable
 Medications: Azithromycin
 Allergy: NKDA
 Immunizations: UTD
 Family History: Unremarkable
 HEADS: Non-smoker; non-alcoholic
beverage drinker; no illicit drug use; no
pets; no animal exposure; no recent
travel; sexually active
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T: 103.5F HR: 155 RR: 30 BP: 90/53 O2 sat: 85%
Gen: ill-appearing; well-developed, in moderate respiratory
distress
HEENT: PERRL, clear conjunctiva, anicteric sclera, dry mucus
membranes, mild diffuse erythema over posterior pharynx, no
tonsillar hypertrophy or exudates, no mucosal lesions, no dental
caries or abscesses
Neck: no meningismus; B/L shotty ACLAD, tenderness to
palpation with distinct nodularity along anterior aspect of right
SCM with distinct nodularity, no erythema or warmth
C/L : SCE, subcostal retractions, tenderness to palpation over
sternal and parasternal areas, bibasilar crackles
Heart: tachycardic, S1S2 normal, no murmur, rub or gallop
Abdomen: soft, NT, ND, + BS, no hepatosplenomegaly
Extremities: FROM, cap refill 2 seconds
Skin: no rash, warm, diaphoretic
Neuro: awake, alert, no focal deficits
DIFFERENTIALS
 CBC
: WBC – 20.5 N - 93% L – 2.8
 BMP : HCO3 – 18
 LFTs : WNL
 Coags: WNL
 CRP : 150 ESR: 180
 HIV ELISA, Monospot test, Hepatitis
panel, Cardiac enzymes: WNL
 Blood Culture : Fusobacterium
necrophorum
 EKG : Sinus tachycardia
LEMIERRE’S
SYNDROME
( A Forgotten Disease)

CLASSIC L.S.:
1. primary infection in
the oropharynx
(pharyngitis, sinusitis, OM,
mastoiditis, odontogenic
infection)
ANDRE LEMIERRE
2. septicemia
3. evidence of internal
jugular vein
thrombophlebitis
4. metastatic focus
 NECROBACILLOSIS
 POSTANGINAL
SEPTICEMIA
 Common in preantibiotic era
 Incidence rate: 1/1 million
 Increase incidence in the last 10 years
 Affects healthy adolescents and young
adults
 Both sexes equally affected
 Majority of reports from Europe and North
America
 Mortality rate: 90% in preantibiotic era; now
6%
FUSOBACTERIUM
NECROPHORUM
FUSOBACTERIUM
NECROPHORUM
 Gram
negative
anaerobic bacillus
 Part of normal flora
 Endotoxins,
Leukocidin &
Hemagglutinin,
Platelet aggregation
 OTHERS:
 Streptococcus
 Bacteroides
 Lactobacillus
 Staphylococcus
 Eikinella
 1. Primary
infection – Pharyngitis
 2. IJV
septic thrombophlebitis – swollen
&/or tender neck
 3. Metastatic
complications – Lungs,
bone, joint, soft tissue, CNS, liver, spleen,
kidney
 “For
a syndrome that is so characteristic,
it is remarkable how often the diagnosis
is missed until an anaerobic gramnegative rod is isolated from blood
culture.”
• Clinicians are unaware of the condition
• Manifestation of septic emboli distract clinicians
from the initial oropharyngeal infection
• Cases present to a wide variety of specialists
 Previously
fit adolescent or young adult
 History of sore throat in preceding week
“Be not deceived by a comparatively
innocent appearing pharynx as the veins
of the tonsil may be carrying the death
sentence of your patient.”
 Onset of high fever and rigors
 Signs of internal jugular venous
thrombosis : neck pain, stiffness, swelling,
trismus, cord sign
 Pulmonary involvement
• Pleuritic chest pain, dry cough, hemoptysis, ARDS
 Bone and joint manifestations
• Septic arthritis, osteomyelitis
 Soft tissue lesions
• Gluteal & abdominal wall abscesses
 Intra-abdominal sepsis
• Abdominal pain, Jaundice, liver & splenic abscess,
Peritonitis
 CNS complications
• Meningitis, cerebral abscess, cavernous sinus &
sigmoid sinus thrombosis
 Renal complications
• Renal abscess, glomerulonephritis, hemolytic-
uremic syndrome
 Hematological complications
• DIC, peripheral ischemia & gangrene
 Viral
Pharyngitis
 Infectious Mononucleosis
 Pneumonia
 Tuberculosis
 Endocarditis
 Blood
Culture
 Culture from involved site
 CBC
 BMP
 LFT’s
 CRP & ESR
 Coagulation profile
 Chest
X-ray
 Ultrasound of Neck
 CT scan of neck
 CT scan of chest
 MRI of neck/chest
MULTIPLE PERIPHERAL
NODULES/PLEURAL EFFUSIONS
FEEDING VESSEL

ANTIBIOTIC THERAPY
• Mainstay of treatment
• Prolonged therapy : 4 to 6 weeks
• Most commonly used agents: Metronidazole; Penicillin/B-
lactamase inhibitor; Imipinem
• Antibiotic of choice:
 Metronidazole
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1. Excellent activity against Fusobacterium
2. Good tissue penetration
3. Bactericidal activity
4. Excellent oral bioavailability
• Mixed infection:
 Metronidazole + Penicillin
 ANTICOAGULANT
 Controversial
• Probably decreases risk of clot extension
• Possibly shortened the course of the disease
• Likely helped avoid surgical drainage
 Indications:
• Cerebral infarct or sinus venous thrombosis
• Persistence of septic emboli despite antibiotic
therapy
 SURGERY
• Drainage of any abscess
• Ligation/excision of Internal Jugular vein
 ADJUNCTIVE THERAPY
• Hyperbaric Oxygen
• Activated Protein C
 Exclusion
of streptococcal infection does
not exclude a bacterial cause in a patient
with severe tonsillar infection
 Key
to diagnosis is AWARENESS & HIGH
INDEX OF SUSPICION
 Patient
started on Ceftriaxone and
Metronidazole
 Thoracentesis done
 Chest pain persisted on D4 of antibiotics
 Echocardiography R/O endocarditis
 Started on Heparin
 Plan: Continue antibiotics for total of 6
weeks and heparin indefinitely; repeat
CT scans after one week

THANK YOU!