A Crick in theNeck: Lemierre Syndrome in a 4-year Old Female Presenting as Fever and Torticollis

Introduction: Described by Dr. Andre Lemierre in a 1936 case series of 20 patients, Lemierre Syndrome (LS) is defined as a septic thrombophlebitis of the internal jugular vein (IJV). LS typically begins as an oropharyngeal infection that advances to the IJV through direct extension through the fascial planes of the neck, or indirect lymphatic or hematogenous spread from the peritonsillar vessels. We present a case of LS in a 4-year-old patient who presents much younger than the typical age range of affected individuals, and who recovered well without any longterm sequelae. Case Description: A 4-year-old ex-27 week female presented with a near 3 week history of intermittent fevers and progressive right-facing torticollis. She had multiple interactions with the health care system over her illness course, and was given diagnoses ranging from general viral syndrome to gingivostomatitis and acute otitis media. Around the 2 week mark, her caretaker described her as having developed a “crick” in her neck while consistently favoring a rightward tilt. On illness day 16, she presented to her pediatrician for routine visit, and was noted to have fever, right tonsillar enlargement, and cervical lymphadenopathy, thereby prompting referral to the emergency department. Her physical exam on admission was additionally significant for a 30 degree rightward head rotation, a swollen and tender right sternocleidomastoid, and submandibular lymphadenopathy. She was resistant to active or passive neck rotation due to discomfort, but was able to traverse the midline with coaxing. Laboratory workup was notable for leukocytosis and thrombocytosis with elevated inflammatory markers, as well as mild transaminitis. Infectious serologic workup was negative for: SARS-CoV-2, Bartonella henselae, Bartonella quintana, EBV, and Mycoplasma. Blood culture showed no growth, but was drawn after antibiotics were given. A CT neck with contrast demonstrated intrinsic occlusion vs compression of the right IJV, and ultrasound and MRI confirmed IJV thrombophlebitis. Discussion: LS is typically associated with Fusobacterium necrophorum infection, a gram-negative anaerobe, with incidence estimated to be around 1 to 3.6 per million per year and mortality rate around 5 to 9%. Significant morbidity is often present, due to dissemination of septic thromboemboli, potentially affecting the CNS, bones/joints, and lungs. The typical age range for LS in pediatric patients clusters around adolescence, but infants as young as 6 months of age have been reported. As oropharyngeal infections most often precede LS, it is important to keep this rare but serious infection on any differential. Conclusion: This patient was diagnosed with Lemierre Syndrome. She was treated with an inpatient course of ampicillin/sulbactam before transitioning to oral amoxicillin/clavulanic acid to complete a total of 4 weeks of antibiotic therapy. All elevated laboratory markers normalized prior to hospital discharge, and the patient had complete resolution of symptoms at outpatient follow up.

Bacterial, fungal and viral zoonoses of pets

Today, pets are the source of numerous infectious diseases that can be transmitted to humans, as a result of their increasingly frequent contact. The most important viruses with zoonotic potential include rabies and influenza viruses as well as rotaviruses and noroviruses. However, the importance of individual viruses varies depending on the climate and infectious disease control systems in certain countries. Dogs, cats, and other increasingly popular types of pets can transmit bacterial zoonotic agents to humans in various ways. In addition to known pathogens such as the bacteria causing leptospirosis, salmonellosis, campylobacteriosis, or brucellosis, the bacteria Pasteurella multocida and Bartonella henselae transmitted by bites or scratches are also significant in human pathology. There has been a significant increase in the prevalence of methicillin-resistant strains of Staphylococcus aureus in isolates originating from pets and the transmission of these strains between humans and animals requires special attention. Furthermore, fungi causing diseases such as sporotrichosis or dermatophytosis are linked to long-term and persistent infections in humans. The epidemiological situation caused by SARS-CoV-2, and the assumption of an interspecies jump of this virus from animals to humans, including its documented presence in domestic cats, dogs, tigers, and martens, have raised the question of the possibility of virus transmission from pets to humans. However, the current pandemic is caused exclusively by SARS-CoV-2 transmission in the human population, and these animals are not a source of infection for humans. A significant number of zoonoses originating from pets is a threat to public health, thus requiring the "One Health" approach through close cooperation between human and veterinary medicine to develop and implement effective health measures for both humans and animals. As part of responsible ownership, pet owners must be informed by veterinarians about measures to prevent infectious diseases and certain risks that are related to keeping certain species of animals.