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Lu Lu Waterhouse, MD PGY-3

July 13, 2012

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Its your first month on wards Previously healthy 15yo female presenting with over 10

days of intermittent fevers, up to 103F, sore throat,fatigue and general weakness

Direct admit from OSH for worsening chest pain thathad started the day before with hypoxia (80% on RA),and dehydration, initial labs significant for WBC 28.6

and Hct 25, received 1L NS bolus at OSH. Had tonsillectomy at OSH 2 weeks prior to this illness

due to swollen left neck and fever, thought to havetonsillar abscess.

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Additional History PMHx: Healthy, no hospitalizations or surgeries other than

tonsillectomy last month.

IMMS: Up to date

MEDS: Ibuprofen, Tylenol PRN fever. Augmentin x5 daysfollowing tonsillectomy.

ALLERGIES: NKDA

FHx: Brother with asthma. Diabetes in family. SHx: Lives with father and brother. Has 2 dogs. No tobacco

exposures. No recent travel. No sick contacts. Deniestobacco, alcohol, or drug use. Denies being sexually active.

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Physical Exam Weight 62kg VS: Temp 38.8, HR 117, RR 38, BP 118/74, O2 sat 97% on 4L NC

GEN: Ill appearing teen, WDWN in moderate respiratory distress.

HEENT: NC/AT, TMs normal, O/P with mild erythema, no exudates, MMM NECK: No LAD, but fullness and tenderness of L sided soft tissue. FROM. CV: Tachycardic, reg rhythm, no m/r/g, 2+ peripheral pulses, 3 sec cap refill RESP: Tachypneic with increased WOB (intercostal and substernal

retractions), poor aeration of bases bilat, no crackles or wheezes. ABD: Soft, NT/ND, +BS, no masses or HSM

GU: did not examine EXT: Warm and well perfused, no cyanosis or edema SKIN: Pale, no rashes or other lesions. NEURO: Alert, oriented. Moving all extremities, normal strength and tone. No

focal deficits.

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Differential Diagnosis?? Previously healthy 15yo female s/p recent tonsillectomy

for tonsillar abscess with 10 days of fever, sore throat,and general malaise.

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Differential Diagnosis ID:

Pneumonia Retropharyngeal absces Peritonsillar abscess

Bacterial tracheitis Epiglottitis Influenza Septic emboli GAS pharyngitis -> bacteremia Lemierres syndrome/ septic

thrombophlebitis Coccidiodes Endocarditis Tuberculosis EBV, CMV HIV/AIDS Tularemia

PULM: Pulmonary embolus Pneumothorax

CV:

Myocarditis Pericarditis Endocarditis Tamponade Arrythmia

HEME/ONC: Lymphoma Leukemia Mediastinal mass

RHEUM: SLE

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Labs & Imaging CBC: WBC 14.0 (8B/80N/6L/6M), Hb 7.6, Hct 22.4, Plts 109

CRP: 18.5, ESR: 55

CMP: within normal

Blood culture: Fusobacterium necrophorum

CT head/neck: Filling defect within left internal jugularvein likely represents non-occlusive thrombus

CT chest: Necrotizing pneumonia in LLL with left pleuraleffusion. Multiple foci of peripheral airspace disease andnodules with cavitation consistent with septic emboli.

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Lemierres SyndromeAKA jugular vein suppurative thrombophlebitis,

postanginal sepsis, or necrobacillosis

Suppurative thrombophlebitis can also occur inperipheral vein or vena cava, but these are usuallyassociated with IV/central catheters

Infection progresses from oropharynx to

parapharyngeal/lateral pharyngeal space to carotidsheath

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Clinical presentation Most commonly previously healthy young adults

Often with preceding pharyngitis (usually w/in 1 week offever onset)

O/P may have erythema, ulceration, or pseudomembrane,but may be normal

Tenderness, swelling, induration may occur in region of thejugular vein, jaw, or sternocleidomastoid

Patients usually present with fever (>39C), rigors,throat/neck pain, and respiratory distress

Septic emboli to the lung are most common, but can bemetastatic too (causing osteomyelitis, septic arthritis)

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Diagnosis Microbiology

From blood culture or culture from infected site

Most common: Fusobacterium necrophorum Usual causative organisms are normal oropharyngeal f lora Ex: other Fusobacterium species, Eikenella corrodens, Strep

pyogenes, Bacteriodes

If catheter associated, then usually skin flora or nosocomial

Radiology CT scan with contrast: filling defects or thrombus w/in

jugular vein with or without soft tissue swelling

U/S of neck: may show jugular vein thrombosis or extentionof thrombus, but less useful in deeper regions

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Treatment Remove focus of infection (eg, intravasc catheter)

Prompt IV antibiotics Empiric therapy: -lactamase resistant -lactam antibiotic (eg,

amp/sulbactam, pip/tazo, ticarcillin-clavulanate, or a carbapenem) If catheter associated, add vancomycin

4-6 weeks antibiotic therapy, w/ minimum 2 weeks IV

Consider surgery if not responding to antibiotics Drainage/removal of peritonsillar or other neck abscesses

Ligation/excision of internal jugular vein Drainage of pulmonary abscesses or empyema

Anticoagulation is controversial No controlled studies

Some support anticoag only if there is extension of the thrombus

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Take home points Suspect Lemierres in patients with antecedent

pharyngitis, septic pulmonary emboli, and persistentfever despite antimicrobial therapy

Especially in previously healthy teens

Typical presentation: fever, rigors, respiratory distress,+/- throat or neck pain

Blood culture and CT scan with contrast (neck/chest)offer definitive diagnosis

Immediate IV antibiotic for anaerobic coverage (addskin f lora coverage if catheter involved)