ABSTRACT
SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Pulmonary cavitary lesions can have varying etiologies. Among these, Lemierre syndrome is an uncommon disease which usually presents with symptoms of upper respiratory tract infection with unilateral neck pain, tenderness or swelling. In recent years, antibiotic stewardship for upper respiratory illnesses has led to its delayed diagnosis resulting in possible increased morbidity and mortality. There have been few reported cases of pulmonary cavitary lesions as the initial presentation of Lemierre syndrome. Our patient presented with incidental bilateral pulmonary cavitary lesions, which led to a diagnosis of Lemierre syndrome. CASE PRESENTATION: A 30-year-old gentleman with no significant past medical history visited urgent care for reproducible chest pain following motor vehicle accident. Chest x ray obtained for suspected rib fracture showed bilateral patchy and rounded opacities, confirmed by CT as bilateral cavitary nodules and consolidation. He was referred to our hospital for further care. Two weeks prior, following administration of COVID booster vaccine, he had developed fever, sore throat, tender lump behind left ear, left jaw and anterior left neck. Most symptoms self resolved in 3-5 days except persistent fever. On arrival, patient was febrile to 102F and hemodynamically stable. Physical examination revealed dry mucous membranes and erythematous pharynx. Labs were significant for leukocytosis of 24.5uL with bandemia and elevated inflammatory markers. Three sets of blood cultures were drawn and empirically started on vancomycin and piperacillin/tazobactam. Echocardiogram ruled out heart valve vegetations. CT angiography of neck showed intraluminal thrombi in left internal jugular vein. Blood cultures finalized to Fusobacterium nucleatum and antibiotics were tapered to metronidazole. Due to persistent fever, anticoagulation was initiated with apixaban 5mg twice daily. Pan CT showed improvement in size of many pulmonary septic emboli. After 48 hours of patient being afebrile, he was discharged on antibiotics and apixaban for at least 4 weeks until surveillance CT angiography showed non progression of thrombus. DISCUSSION: Lemierre syndrome is septic thrombophlebitis of internal jugular vein which presents within 1-3 weeks following upper respiratory tract infections with multi-system complications. Management involves prolonged antibiotic course with use of anticoagulation and vein stripping still being debated. Our patient came to the hospital with an incidental finding of bilateral cavitary pulmonary lesions which went on to be diagnosed as Lemierre syndrome from positive blood cultures and CT angiography findings. CONCLUSIONS: Lemierre syndrome is an uncommon disease with mortality up to 18%. A call out to health care providers to keep a low threshold for its diagnosis in patients with initial presentation of bilateral pulmonary cavitary lesions, warranting prompt management. Reference #1: Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore). 1989 Mar;68(2):85-94. PMID: 2646510. Reference #2: Golpe R, Marín B, Alonso M. Lemierre's syndrome (necrobacillosis). Postgrad Med J. 1999 Mar;75(881):141-4. doi: 10.1136/pgmj.75.881.141. PMID: 10448489;PMCID: PMC1741175. Reference #3: Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre's syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect. 2020 Aug;53(4):513-517. doi: 10.1016/j.jmii.2020.03.027. Epub 2020 Apr 4. PMID: 32303484. DISCLOSURES: No relevant relationships by Sumukh Arun Kumar No relevant relationships by Megna Machado No relevant relationships by Sushmita Prabhu No relevant relationships by PAWINA SUBEDI No relevant relationships by Mithil Gowda Suresh No relevant relationships by Bradley Switzer