Busse, Claudia, MD

LaRussa, Liborio, MD

Mangla, Saisho, DO

English

Busse, Claudia F., MD

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of PediatricsFinding a Foal Amongst the Zebras: AnUncommon Presentation of Lemierre’s SyndromeSaisho Mangla DOLehigh Valley Health Network, saisho.mangla@lvhn.orgClaudia Busse MDLehigh Valley Health Network, claudia.busse@lvhn.orgLiborio LaRussa MDLehigh Valley Health Network, Librorio.Larussa@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/pediatricsPart of the Pediatrics CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtMangla, S., Villalobos, T., Busse, C., Larussa, L. (2015, March 29). Finding a Foal Amongst the Zebras: An Uncommon Presentation ofLemierre’s Syndrome. Poster presented at: Vignettes category at the Society of Hospital Medicine's Annual Meeting in National Harbor,MD. Timeline© 2015 Lehigh Valley Health NetworkSaisho Mangla, DO, Tibisay Villalobos, MD, Claudia Busse, MD and Liborio Larussa, MDObjectives	 •	 	To	recognize	the	value	of	tissue	biopsies	in	the	step	wise	work	up	of	fever	of	unknown	origin	(FUO).	 •	 	To	consider	Lemierre’s	syndrome	in	the	differential	diagnosis	of	FUO,	even	when	all	of	the	classic	findings	are	not	present.			 •	 	To	understand	the	potential	complications	of	Lemierre’s	syndrome	and	importance	of	appropriate	treatment.Patient Presentation8 year old previously healthy hispanic boy	 •	 	History	of	daily	fever	spikes	102-105F	in	the	afternoons	for	>14d	with	rigors	 •	 	Only	complaint		was	vague	right	upper	quadrant	abdominal	pain		 •	 	Three	visits	to	ambulatory	setting	failed	to	reveal	possible	sourceInitial Evaluation	 •	 	Benign	physical	exam	on	presentation.	No	oral	lesions,	facial	tenderness,	pharyngeal	exudates,	or	erythema.		 •	 	CT	abdomen:	Normal.	 •	 	Infectious	workup:		 	 	 –	 	Bacterial	culture	on	day	1	positive	for	strep	mitis	and	oralis	treated	with	IV	vancomycin	and	ceftriaxone	for	5	days	until	follow	up	cultures	sterile.		 	 	 –	 	Bacterial	culture	on	day	15	positive	for	strep	constellatus	treated	w/	vancomycin	and	ceftriaxone	x	7	days						 •	 	Elevated	ESR	123	(nml	0-20)	and	CRP	255	(nml	<	7.0)	 •	 	Rheumatologic	workup	negative		 •	 	Oncology	evaluation	including	bone	marrow	aspiration	ruled	out	hematologic	malignancy.		 •	 	Leukocyte	tagged	bone	scan	normal		 •	 	US	Neck:	Normal	 •	 	Venous	doppler	Right	Neck:	Normal.	No	DVT.		 •	 	CXR:	normal	 •	 	MRI	chest:	no	evidence	of	blood	vessel	abnormality	but	did	reveal	a	small	cystic	lesion	posteriorly	in	the	right	lower	lobe	adjacent	to	the	pleura.	Outcome:	After	continued	daily	bimodal	fevers	for	2.5	weeks,	he	was	afebrile	for	4	days	on	prednisolone	for	presumed	juvenile	idiopathic	arthritis.	He	was	discharged	home	in	stable	condition	with	follow	up	outpatient	with	imaging	to	monitor	cystic	lesions.	Subsequent Course	 •	 	Readmitted	5	days	later	for	return	of	fever	and	complaints	of	right	lower	chest	pain.		 •	 	Chest	CT:	3	pleural/subpleural	lesions	in	lower	right	chest.		 •	 	Venus	duplex	UE	for	vasculitis:	Near	occlusive	thrombus	of	right	basillic	and	cephalic	veins.	 •	 	Lung	biopsy	via	open	thoracotomy	and	wedge	resection.	Anaerobic	lung	tissue	culture:		Fusobacterium nucleatum			 •	 	Diagnosis	of	Lemierre’s	Syndrome.		 •	 	CT	Head:	 	 	 –	 	Non-occlusive	venous	sinus	thrombosis	in	the	distal	right	transverse	sinus	and	right	sigmoid	sinus	with	minimal	extension	into	the	right	internal	jugular	vein.		 •	 	CT	Maxi-facial	 	 	 –	 	Paranasal	sinus	disease	with	complete	opacification	of	left	maxillary	sinus.Outcome:	Defervesced	within	48h	of	IV	meropenem	and	completed	5	weeks	of	IV	ertapenem	as	outpatient	with	complete	resolution	of	his	symptoms.	Prophylactic	enoxaparin	was	given	while	the	PICC	line	was	in	place.Clinical Features and Complications of Lemierre’s Syndrome	 •	 	Classic	Presentation:	Septic	thromboplebitis	of	the	internal	jugular	vein,	but	thrombophlebitis	of	other	veins	described	as	well.		 •	 	Most	common	pathogen:	Fusobacteria,	normal	flora	of	oropharynx,	anaerobic	Gram	-	bacilli		 •	 	Commonly	follows	primary	oropharyngeal	infection	 •	 	Symptoms:	sore	throat,	neck	pain	and	swelling,	high	fevers,	rigors	 •	 	Timing:	Primary	Infection	leading	to	local	invasion	of	IVJ	and	septic	thrombophlebitis	in1-3	week	period	 •	 	Complications:	Pulmonary	Infections,	Osteoarticular	Infections,	CNS	infections,		 Mortality	Rate	6-18%Diagnosis and Treatment	 •	 	Culture:	Anerobic	Gram	-	rod,	can	take	5-8	days	to	grow	 •	 	Imaging:	CT	neck	best	diagnostic	modality		 •	 	Treatment:	prolonged	course	of	IV	antibiotics	for	4-6	weeks		 	 									Carbapenems	 	 									Metronidazole	+	macrolide		 •	 	Anticoagulation:	Debatable	Take Home Points	 •	 	Lemierre’s	Syndrome	must	be	considered	in	all	patient	with	history	of	oropharyngeal	infection	who	presents	with	neck	pain.		 •	 	Clinical	picture	in	children	can	be	more	atypical	and	original	oropharyngeal	infection	may	have	resolved	by	the	time	patient	presents	with	limited	exam	findings.			 •	 	Four	to	six	weeks	of	antibiotics	are	indicated	to	avoid	the	potentially	severe	complications,	including	pulmonary	emboli	and	sinus	venous	thrombosis.ImagingChildren’s Hospital at Lehigh Valley Health Network, Allentown, PAFinding a Foal Amongst the Zebras: An Uncommon Presentation of Lemierre’s SyndromeREFERENCES:1.	 	Brook	I.	Fusobacterial	infections	in	children.	Curr	Infect	Dis	Rep.	2013	Jun;15(3):288-94.	doi:	10.1007/s11908-013-0340-6.	PubMed	PMID:	23616183.2.	 	Kuppalli	K,	Livorsi	D,	Talati	NJ,	Osborn	M.	Lemierre’s	syndrome	due	to	Fusobacterium	necrophorum.	Lancet	Infect	Dis.	2012	Oct;12(10):808-15.	doi:	10.1016/S1473-3099(12)70089-0.	Epub	2012	May	25.	Review.	PubMed	PMID:	22633566.3.	 	Shiber	J,	Fontane	E,	Rabinowitz	R,	Gens	D,	Habashi	N,	Scalea	T.	Incomplete	lemierre	syndrome.	Pediatr	Emerg	Care.	2015	Jan;31(1):39-41.	doi:	10.1097/PEC.0000000000000327.	PubMed	PMID:	25560619.Figure 2.MRI	Chest:	Cystic	lesion	in	R	lung	adjacent	to	pleura.	Figure 1.CT	Chest:	Cystic	Lesion	to	R	lung.	Figure 4.CT	maxofacial	outlining	complete	opacification	of	the	left	maxillary	sinus.Figure 3.CT	Head	outlining	nonocclusive	venous	sinus	thrombosis	within	the	distal	right	transverse	sinus.0 5 10 15 20 25 30 35 40Day 02 weeks of feverand RUQabdominal pain.Day 30Readmitted return of feverand complaints of rightlower chest pain. CT chest-3 pleural/subpleurallesions have developed inlower right chest.Day 35Anaerobic lung tissueculture: FusobacteriumNucleatum & Strep.Constellatus. CT Maxi-facial:complete opacification ofthe left maxillary sinus. CTHead: venous sinusthrombosis in the distal righttransverse sinus.Day 41Dischargedwith 4 weeksof IVertapenem +enoxaparinprophylaxis.Day 24Discharged withpresumptive JIAdiagnosis afterremaining afebrilefor 4 days.Day 1Blood cx: Strep mitisand oralis. Treated w/vancomycin andceftriaxone for 5 days.Repeat culture sterile.Day 17R neck pain-Negative duplex,ultrasound andbone scan.Day 21MRI chest- Smallcystic lesionposteriorly in theright lower lobeadjacent to thepleura.Day 31Venous Duplex forvasculitis: Nearcomplete occlusivethrombus of theright basilic andright cephalicveins.DAYS DAYSDay 15Blood culturepositive for strepconstellatus.Normal HEENTexam. Treated w/vancomycin andceftriaxone x 7days.4 weeks afterCompletion of IVAntibioticsNormal Paranasalsinus x ray.4 Weeks

Finding a Foal Amongst the Zebras: An Uncommon Presentation of Lemierre’s Syndrome

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Finding a Foal Amongst the Zebras: An Uncommon Presentation of Lemierre’s Syndrome

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