Lemierre’s Syndrome presenting with neurological and pulmonary symptoms: Case report and review of the literature
A 15-year-old previously healthy young female presented to the emergency department of our tertiary care institute with a 7-day history of high-grade fever, painful neck swelling, dry cough and progressive breathlessness. She also had history of vestibulitis of nose prior to onset of fever, but there was no history of chest pain, hemoptysis and orthopnea. On evaluation, she was febrile (100.4°F) with pulse-110/min, respiratory rate-30/min, blood pressure-100/60 mmHg and saturation at room air-86%. Her physical examination showed pallor, with taut and tender neck muscles. Small multiple tender cervical lymph nodes were also noticed. The oropharynx was normal and there was no evidence of parapharyngeal or retropharyngeal abscess on examination. Chest examination showed bilateral crepitation with reduced vesicular breath sounds on both bases. Central nervous system evaluation revealed left lateral rectus muscle palsy. Cardiovascular and gastrointestinal systems were unremarkable clinically. Her initial investigations showed a total leukocyte count of 16,400 cs/mm (neutrophils 85%, lymphocytes 15%), hemoglobin-8.5 gm% and platelet count-35,000 cs/mm, with normocytic normochromic blood film morphology. The clinical chemistry was unremarkable, except mild hypoalbuminemia. Chest X-ray showed evidence of right lower zone consolidation and pleural effusion []. In view of the above findings, an immediate possibility of neck vein thrombosis was considered and a contrast-enhanced CT and ultrasound Doppler of the neck were obtained, which showed left internal jugular venous thrombosis with multiple enlarged lymph nodes and subcutaneous edema []. A contrast-enhanced magnetic resonance imaging (MRI) of the brain was performed to localize the cause of left sixth nerve palsy, which revealed an area of nonenhancement in the left cavernous sinus suggestive of thrombosis []. A 2D-echocardiography was carried out to rule out infective endocarditis, which was also normal. Pleural fluid analysis showed neutrophilic predominant exudate with low glucose values and growth consisting of gram negative bacilli, identical in characteristics with Fusobacterium. She was initially being put on broad-spectrum i.v. antibiotics like augmentin and metrogyl, which was changed in concordance with culture sensitivity results to meropenem, levofloxacin and teicoplanin. All other cultures including blood, sputum, urine and stool were sterile. Right empyema thoracis was drained but, in view of multiloculated collection, it also required intrapleural streptokinase instillation. The patient was continued on the above antibiotics along with oxygen supplementation and supportive treatment in the form of anticoagulants to which she responded dramatically and there was rapid improvement in the general condition of the patient. Anticoagulation was not given initially due to thrombocytopenia but, because the response to antibiotics was slow, anticoagulants were added in the form of low molecular weight heparin once her platelet count was above 75,000/mm3. She responded very well to the treatment and improved clinically as well as radiologically, with resolution of consolidation and effusion on serial chest X-rays. Anticogulation was given for a total duration of 4 weeks and antibiotics were continued for a total of 6 weeks. Follow-up Doppler neck showed no evidence of residual internal jugular venous thrombosis. The patient has now recovered completely and is being followed-up in out-patient department on a regular basis for the last 6 months.