Lemierre's Syndrome in COVID Pandemic: Is there an Association?

Background: Lemierre's syndrome is an uncommon life-threatening condition characterized by septic thrombophlebitis of the internal jugular vein (IJV), anaerobic sepsis, and metastatic infections. Case description: A 57-year-old diabetic male presented to the emergency department with progressively increasing left-sided neck swelling. A contrast-enhanced computed tomography of the neck revealed an air-containing abscess showed a long-segment thrombus in the left internal jugular vein with septic embolization to the right upper lung. He was also positive for SARS-CoV-2 infection. He underwent emergency drainage of the abscess along with culture appropriate antibiotics. Two days postprocedure, he developed atrial fibrillation and received anticoagulation treatment for 3 months. Discussion(s): This case report adds to the growing body of literature of co-occurrence of Lemierre's syndrome in SARS-CoV-2 infection and discusses the possible associations between the two. Besides, it also highlights Klebsiella pneumoniae as an uncommon pathogen causing Lemierre's syndrome.Copyright © The Author(s). 2022 Open Access.

Lemierre's Syndrome in the External Jugular Vein Precipitated by COVID-19 Infection.

Lemierre's syndrome is a condition when an oropharyngeal infection, typically from Fusobacterium necrophorum, causes thrombophlebitis of the internal jugular vein. There have been few case reports of Lemierre's syndrome affecting the external jugular vein, but to our knowledge, this is the first case report where COVID-19 infection is the prime suspect for causing this syndrome. SARS-CoV-2 infection, known to cause hypercoagulability and immunosuppression, increases the risk of deep venous thrombosis and secondary infections. We report a case of a young male with no known risk factors who developed Lemierre's syndrome as a complication of COVID infection.

Arcanobacterium haemolyticum bacteremia presenting as severe sepsis: A case report and review of the literature.

Objective: to describe a case of severe sepsis and complicated bacteremia caused by Arcanobacterium haemolyticum and review similar cases in the literature. Case summary: A 26-year-old gentleman with a history of epilepsy presented with symptoms of sore throat, productive cough, periumbilical abdominal pain, watery diarrhea, nausea and vomiting, subjective fevers along with progressive jaundice for seven days. The patient had acute fulminant liver failure, septic shock, and Multi-organ failure. He required vasopressors, underwent intubation, and had grown Arcanobacterium haemolyticum in the blood and Bronchoalveolar lavage samples. He developed a peritonsillar abscess and cavitary pneumonia and required chest tube drainage followed by thoracotomy for hemothorax. The patient improved on Ampicillin-Sulbactam treatment and was treated with a total antibiotic duration of 6 weeks. He fully improved on post-discharge follow-up. Discussion: Arcanobacterium haemolyticum is a Gram-positive (sometimes Gram variable), catalase-negative facultatively anaerobic, non-motile, non-spore-forming, and variably ß-hemolytic and is known to be a cause of pharyngitis and skin and soft tissue infections. Rarely A. Haemolyticum can be associated with severe systemic infections such as infective endocarditis, systemic abscesses, osteomyelitis, and septicemia. In previous literature reviews, the source of A. haemolyticum depended on the host, and pharyngeal and upper respiratory sources were likely to be associated with immunocompetent hosts. Conclusion: A. haemolyticum should be included in the differential diagnosis of bacterial pharyngitis complicated by severe systemic illness. Penicillins are the most commonly used antibiotics for treating A. haemolyticum bacteremia, and macrolides can be used for Penicillin's treatment failure.

Not all shortness of breath and throat pain is COVID

Case Report: A previously, healthy 18-year-old female presents to a Pediatric Emergency Medicine Department with shortness of breath, fever, and worsening throat and abdominal pain for 3 days. She had a sick contact, a teacher that tested positive for COVID-19 2 weeks prior to presentation. She denies runny/stuffy nose, cough, loss of taste/smell, or rashes/lesions. She denies any significant past medical history including allergies, as well as any history of smoking or any illicit drug use. Upon arrival to the ED, the patient was noted to be tachycardic, hypotensive and febrile. There were no desaturations. Initial physical examination revealed a generally uncomfortable female that was alert and oriented, with noted tenderness over the right anterior neck region, diffuse cervical lymphadenopathy, and painful neck range of motion. Her pharynx was noted to be erythematous without exudates or any unilateral tonsillar swelling. In the ED patient received IV fluid resuscitation and was started on norepinephrine drip, broad spectrum antibiotics. Initial lab workup revealed an anion gap metabolic acidosis, likely secondary to uremia or lactic acidosis from poor perfusion in setting of sepsis and hypovolemia. BUN and creatinine were elevated, likely due to an acute kidney injury (AKI) secondary to hypovolemia. The patient was also found to have an elevated LDH, fibrinogen, and mild elevation of AST. D-Dimer was elevated at 29 000. Covid PCR, Rapid Strep, and respiratory PCR panel were negative. Her chest X-ray (CXR) was negative and ECG showed sinus tachycardia. Given the patient's history of throat and neck pain with shortness of breath, in the setting of a septic picture, a CT scan of neck, chest, abdomen was ordered prior to transferring the patient to the PICU. CT scan of the chest revealed small patches of consolidation with ground glass opacities in the right lung apex, as well as an nearly occlusive, acute thrombosis of the anterior right facial vein. The patient's initial blood cultures grew gram negative bacilli which later were revealed to be Fusobacterium necrophorum. These findings are consistent with Lemierre's syndrome. The patient was treated in the PICU on vasopressors, heparin anticoagulation, and antibiotics for 6 days and discharged with a course of Augmentin. Lemierre's syndrome is an infectious thrombophlebitis of the internal jugular vein. First described by Andre Lemierre in 1936, it begins as a bacterial pharyngitis, generally developing into a peritonsillar abscess or other deep space neck infection with progressive erosion into the internal jugular vein. Diagnostic criteria for Lemierre's syndrome includes radiographically evidence of thrombophlebitis of the internal vein and positive blood cultures. CT and MRI can help make the diagnosis, but are not always required. Treatment is prompt intravenous antibiotics with beta-lactamase penicillins, metronidazole, clindamycin, and third generation cephalosporins. [Figure presented] Copyright © 2023 Southern Society for Clinical Investigation.

INCIDENTAL PULMONARY CAVITARY LESIONS AS AN UNCOMMON PRESENTATION OF LEMIERRE SYNDROME

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

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.

Lemierre syndrome associated mycotic cavernous sinus thrombosis and carotid aneurysm after COVID-19.

Purpose: The purpose of this article is to report a case of Lemierre syndrome associated mycotic aneurysm of the intracavernous carotid artery leading to cavernous sinus syndrome in an otherwise healthy, young man in the setting of COVID-19 infection. Observations: An 18-year-old, otherwise healthy male athlete developed fever, chills, and headache and was found to be positive for COVID-19 with gram negative bacteremia. While on systemic antibiotic treatment, he developed acute, left-sided, 6th nerve palsy and was found to have bacterial sinusitis, left-sided intracavernous mycotic aneurysm, and cavernous sinus thrombosis on imaging studies. Despite systemic antibiotic and antiplatelet therapy, he developed progressively worsening left-sided ophthalmoplegia and vision decline. He subsequently underwent left internal carotid artery embolization and cervical internal carotid artery sacrifice with excellent outcome. Conclusion and importance: Lemierre syndrome can have atypical presentations and complications, including cavernous sinus thrombosis and mycotic aneurysms. Recognition of signs and symptoms, including progressive multiple cranial neuropathies, can aid in early diagnosis and management, which requires multidisciplinary care tailored to each individual based on risk of intervention.

Lemierre syndrome: A forgotten disease at the time of CoViD-19 pandemic

Background: Lemierre syndrome is a potentially life-threatening sequela of head/neck district infection, tipically due to Fusobacterium necrophorum infection, characterised by trombophlebitis of internal jugular vein with possible septic embolisation to different organs. Typical treatment involves prompt antibiotic therapy and surgical drainage of infected collections, while the role of anticoagulation is controversial. Presentation of the cases: Two previously healthy young males were admitted to our Internal Medicine Department, within a few weeks from each other, with an initial diagnosis of suspected meningoencephalitis in the course of SARS-CoV-2 infection. Symptoms reported at home were only fever and headache. In both cases brain MRI showed intraluminal filling defect in the internal jugular vein, in addition to acute sinusopathy in one case, and peritonsillar abscess in the other. First patient had blood cultures positive for Fusobacterium necrophorum, while they were negative in the second one. Ceftriaxone and metronidazole and anticoagulant therapy were started, with gradual clinical improvement. Conclusions: We describe two delayed presentations of Lemierre syndrome in two young males, with an atypical onset, in which SARS-CoV-2 infection has made diagnosis even more difficult: on one hand, the initial, nonspecific symptoms can lead to a focus on ongoing viral infection;on the other, the postponement of routine medical visits during the CoViD-19 pandemic can lead to a delay in the diagnosis, leading to more serious and complex presentations at a later date.

Not All Pulmonary Densifications Are COVID-19: A Case Report About Lemierre's Syndrome.

Lemierre's syndrome is a rare and a life-threatening disease characterized by anaerobic bacteraemia associated with thrombosis of the internal jugular vein. Odynophagia, otalgia, odontalgia, dyspnoea, cough and fever are the most frequent manifestations. We describe a case of a 37-year-old woman who was admitted to the emergency room due to fever, odynophagia, dyspnoea, myalgia, and pleuritic chest pain. She had hypoxaemia and increased systemic inflammatory markers. The chest CT showed parenchymal densification compatible with severe acute respiratory syndrome coronavirus infection, although all three polymerase chain reaction testing were negative. The neck CT showed occlusion of the left cervical internal jugular vein. She was treated with antibiotics and was discharged. With the reported clinical case the authors intend to clarify the importance of differential diagnosis and the diagnosis of other infectious respiratory conditions at the time of a global pandemic.

Case Report: Cerebrovascular Events Associated With Bacterial and SARS-CoV-2 Infections in an Adolescent.

Neurologic manifestations associated with Covid-19 are increasingly reported, especially stroke and acute cerebrovascular events. Beyond cardiovascular risk factors associated with age, some young adults without medical or cardiovascular history had stroke as a presenting feature of Covid-19. Suggested stroke mechanisms in this setting are inflammatory storm, subsequent hypercoagulability, and vasculitis. To date, a handful of pediatric stroke cases associated with Covid-19 have been reported, either with a cardioembolic mechanism or a focal cerebral arteriopathy. We report the case of an adolescent who presented with febrile meningism and stupor. Clinical, biological, and radiological features favored the diagnosis of Lemierre syndrome (LS), with Fusobacterium necrophorum infection (sphenoid sinusitis and meningitis) and intracranial vasculitis. The patient had concurrent SARS-CoV-2 infection. Despite medical and surgical antimicrobial treatment, stroke prevention, and venous thrombosis prevention, he presented with severe cerebrovascular complications. Venous thrombosis and stroke were observed, with an extension of intracranial vasculitis, and lead to death. As both F. necrophorum and SARS-CoV-2 enhance inflammation, coagulation, and activate endothelial cells, we discuss how this coinfection may have potentiated and aggravated the usual course of LS. The potentiation by SARS-CoV-2 of vascular and thrombotic effects of a bacterial infection may represent an underreported cerebrovascular injury mechanism in Covid-19 patients. These findings emphasize the variety of mechanisms underlying stroke in this disease. Moreover, in the setting of SARS-CoV-2 pandemic, we discuss in what extent sanitary measures, namely, lockdown and fear to attend medical facilities, may have delayed diagnosis and influenced outcomes. This case also emphasizes the role of clinical assessment and the limits of telemedicine for acute neurological condition diagnosis.