(1609) A Unique Presentation of Lemierre Syndrome

Introduction: Lemierre Syndrome(LS) is a condition characterized by oropharyngeal infection with metastatic spread, thrombophlebitis of internal jugular vein, and blood/sterile site culture with fusobacterium necrophorum(FN). The pathophysiology is oropharyngeal bacteria tracking into the neck, invading surrounding structures (often internal jugular vein), causing aggregation of platelets, and widespread dissemination. LS has been associated with multiorgan septic emboli, septic joints, osteomyelitis and myositis.

Description: The patient was a 20s-year-old male without pertinent past medical history who presented to the Emergency Department(ED) after being found down, reporting a week-long course of fevers, diarrhea, vomiting, throat/neck pain, and migratory joint pain. He was hypothermic, with acute renal failure, hyperbilirubinemia, and pancytopenia. Imaging showed subcutaneous air in right thigh, osteomyelitis of the acetabulum, and septic emboli in lungs, liver and spleen. He was urgently taken for debridement of suspected necrotizing soft tissue infection after becoming hypotensive. Operative course notable for pre-induction cardiac arrest with return of spontaneous circulation within 1 round, and no evidence of necrotizing fasciitis. He continued to worsen, requiring 5 vasopressors, stress dose steroids, and continuous renal replacement therapy. Initial antibiotics (vancomycin, cefepime and clindamycin) were broadened to vancomycin and piperacillin-tazobactam. Infectious diseases team had suspicion for endocarditis or LS. He had bedside echocardiogram without vegetations. He continued to have refractory metabolic acidosis and hypotension, prompting discussion with the family and transition to comfort care, with patient dying shortly after. Autopsy showed diffuse septic emboli without vegetations. Blood cultures came back positive for FN.

Discussion: Initial suspicion for LS was low given very mild throat/neck tenderness with more prominent gastrointestinal or musculoskeletal symptoms, which is less commonly reported. We suspect small internal jugular thrombosis that was not captured on imaging given his mildly tender and swollen face/neck. High suspicion for LS should be kept with septic emboli, as treatment is early initiation of anaerobic coverage antibiotics.