Name of presentation

Name of presentation

The Forgotten Disease Dr. Amera Elzubeir- University Hospital Birmingham. The case-1900hrs Master AD 18 year old male 1st week at university

PC: Generally unwell HPC: Tonsillitis 5/7 ago D&V Fever & Rigors Pleuritic chest pain, cough & sputum PMHx/DHx- Nil On Examination A- Patent B- Peripherally cyanosed

RR- 30 Sats-75% RA Auscultation- reduced A/E & crepitations Rt Base C- HR-110 Soft BP- 95/42 ++central tenderness BS-Present CRT <2sec, warm No masses

HS-I-II-O Good urine output D-GCS 15 E-Calves SNT, No Rash, 40.2 Investigations ABG on 35%- pH-7.47 p02-11.66 pCO2- 3.65 HCO3- 22.5

Lactate-2.01 ECG- Sinus tachycardia Investigations Blood Results-2000hr

Na 129 K 4.1

Urea 14.7 Creatinine 133 GFR 64 Albumin 28 ALT 38 ALP 184 Bilirubin 13 Corrected Ca 2.3

CRP 302 WCC 21.81 Neutrophils 18.70 Monocytes 1.67 Lymphocyte 1.25 Current problems 1. Probable CAP 2. Type 1 Respiratory Failure

3. AKI Investigations pending2200hrs HIV Atypical serology Urinary leigonella and pneumococcal Viral studies Throat swab Blood cultures

Sputum MC&S Amylase Treatment IV benzylpenicillin and clarithromycin

IV Fluids Analgesia Antipyretics 43hrs post admission Patient improving Preliminary blood cultures- gram variable cocci and gram positive rods Tx- IV Tazocin and oral

clarithromycin 67 hrs post admission Patient improved further Further micro input-Anaerobes ? Pharyngeal source Tx- IV tazocin & oral clarithromycin under micro advice 72hrs post admission

Reg on call ASTP RE: spiking temperature Appearance of maculopapular rash ? EBV Investigations day 6 EBV POSITIVE HIV NEGATIVE Day 6 ward round

Patient much improved Apyrexial for 48hrs No rash Pain free

Throat still ++ hyperaemic PLAN- Repeat CXR Repeat CXR Another phone call from Micro Blood cultures grown: 1. FUSOBACTERIUM NECHROPHORUM

Fusobacterium Necrophrum Anaerobic gram negative bacilli First described as a pathogen in animals First described in 1900 by Courmont & Cade- post anginal septicemia Andre Lemierre, 1936- published 20 case reports of a syndrome. syndrome is so characteristic that

a mistake is almost impossible. Lemierres Syndrome Aka Post anginal septicemia or necrobacillosis. Rare Mortality rate- 8 to 30% M>F A syndrome characterised by: Oropharyngeal infection

Anaerobic septicemia Clinical/radiological evidence of internal jugular vein thrombosis Fusobacterium Necrophurm Normal inhabitant of-oral cavity, genital tract, GI tract. Most virulent Common in pre-antibiotic era & usually fatal.

Substantial decrease-1940. Resurgence since late 1990. Aetiology Unusual ability to affect previously healthy young adults humans F. LPS Endotoxin Platelet NECROPHORU

M aggregation Lateral pharyngeal space TONSILS Posterior compartment aggregation

IJV THROMBOPHLEBITIS Septic emboli Metastatic infections Pathogenesis

Reason why F. Necrophum becomes invasive is unknown ? EBV as risk factor ? Enhancement of toxins Clinical presentation Tonsillitis Hyperaemic pharynx

Nil Oropharynge al IJV/peritonsilar vein thrombophlebitis Local signs - Pain - Swelling - Induration - Trismus

Persistent fever Septic/metastatic emboli -Lungs -Bone -Liver/spleen -Brain -Skin Diagnosis

Causative organism isolated. Suspicion of IJV thrombophlebitis must be objectively confirmed. CT Neck + contrast U/S Treatment IV antibiotics as mainstay Prolonged-due to endovascular nature

Sensitive to: metronidazole, penicillin, clindamycin & chloramphenicol Some strains produce Betalactamase. Role of anticoagulation is controversial. Our patient-Lemierres syndrome A syndrome characterised by:

Oropharyngeal infection Anaerobic septicemia Clinical/radiological evidence of internal jugular vein thrombosis Ultrasound Neck CT Head & Neck CT Report

Thrombus seen in the Lt IJV, and extending towards the Lt tonsil. Inflamed tonsils seen bilaterally, with pockets of gas seen within the tonsils-compatible with tonsillitis. Small abscesses in upper chest which corresponds to septic emboli from the jugular lesion. Take home message

High index of suspicion Blood cultures Radiological/clinical confirmation of suspected IJV thrombosis Prolonged treatment with IV antibiotics Uncertain role of anticoagulation References 1. Golpe R, Marin B, Alonso M. Lemierres syndrome

(necrobacillosis). Postgrad Med J 1999, 75:141-144. 2. Lu et al. Lemierre syndrome following oropharygeal infection: A case series. J Am board of fam med 2009; 22:79-83. 3. Eilbert W, Singla N. Lemierres Syndrome. International journal of Emergency medicine 2013, 6:40-45. 4. Ridgway et al. Lemierre syndrome: a paediatric case series and review of the literature. Am J Otolaryngology- Head and neck medicine and surgery 2010;38-45.

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