Beta hemolytic streptococcus induced septic pulmonary emboli complicated by lemierre's syndrome

ABSTRACT

Introduction-Septic pulmonary emboli are common in intravenous drug users. Often, they are accompanied by right-sided endocarditis. We present an uncommon case of sepsis with pulmonary emboli without endocarditis and complicated by Lemierre's syndrome. Case-A 30-year-old man presented with five days of high fevers, dyspnea, sore throat, nonproductive cough, polyarthralgia, and myalgias. He worked as a butcher, had no sick contacts or recent travel, was a nonsmoker, did not vape or use illicit drugs, and had no rash. He was febrile at 102°F, tachycardic, hypotensive, tachypneic, and hypoxic to 84% on room air. The examination was notable for bilaterally decreased breath sounds and no murmurs were heard. Investigations revealed leukocytosis, thrombocytopenia, lactic acidosis, elevated inflammatory markers (D-dimer, lactate dehydrogenase, C-reactive protein), and transaminases. Initial chest-Xray (CXR) revealed prominent interstitial markings (Fig-1A). Oxygen supplementation by high flow nasal cannula and empiric broad-spectrum antibiotics were initiated. COVID-19 testing was negative twice. Blood cultures grew group-C beta-hemolytic streptococci (GCS), and follow-up CXR (Fig-1B) and computed tomogram (CT) thorax (Fig-1C) were concerning for pulmonary septic emboli along with bilateral consolidations. Both transthoracic and transesophageal echocardiograms were negative for vegetations. The antibiotic regimen was modified according to sensitivity. Further patient interview revealed that he was handling meat with an open, deep finger wound a month ago. Due to persistent left-sided neck pain, a CT neck was performed revealing left sided internal jugular vein thrombophlebitis (Fig-1D). Hence, anaerobic antibiotic coverage was added considering Lemierre's syndrome. Further, bilateral upper extremity deep and superficial venous thrombi were detected and the patient was started on therapeutic anticoagulation. Hypercoagulability workup was concerning for antiphospholipid antibody syndrome with a positive anti-cardiolipin antibody screen. A follow-up CT thorax revealed numerous bilateral septic emboli, with some cavitating (Fig-1E). The patient improved over the next week and was slowly weaned off supplemental oxygen. He was discharged home on Coumadin and completed four weeks of antibiotics. He was doing well at his follow-up. Discussion-Invasive disease due to GCS is uncommon, with an incidence of 4%-6%. Occasionally, they have been implicated for septicemia in meat handlers and with exposure to animals. GCS bacteremia can result in multiple system involvement, presenting with symptomatology like our patient. Beta-lactam antibiotics remain an effective treatment. Lemierre's syndrome is rare, and commonly associated with pharyngitis and anaerobes, though rarely, septic emboli and streptococci have been implicated.