Lemierre's syndrome presenting with septic shock
A 24-year-old young male weighing 80 Kg, with no co-morbidities presented with history of sore throat of 10 days duration, associated with difficulty in swallowing. 4 days before presenting to the hospital, he developed pain and swelling on the left side of the neck and had a 2 day history of severe throbbing headache with vomiting and restlessness. Examination of his oral cavity showed a bulge in the posterior pharyngeal wall, more towards left side and the uvula was deviated to the right. He was febrile, tachycardic, and had tender swelling on the left side of the neck involving the angle of mandible and upper third of the sternomastoid. Further systemic examination was unremarkable and his Hb 13.3 gm%, total count of 9800 cells/cumm, platelet count 282,210 cells/cumm, ESR 37 mm/h and was HIV negative. Magnetic resonance imaging of neck revealed a left parapharyngeal abscess and magnetic resonance (MR) venogram [] showed thrombosis of the left IJV and reduced flow or stasis in left transverse and sigmoid sinuses. Other investigations were unremarkable. A diagnosis of Lemierre's syndrome was made. The parapharyngeal abscess was drained under general anesthesia and was empirically started on imepenem awaiting culture reports of aspirated pus and devitalized tissue. Fondaparinux was started in view of thrombosis of left IJV.\nOn the 2nd post-operative day, patient had persistent hypotension with systolic pressures between 70 and 90 mmHg, not responding to repeated fluid boluses. The total count decreased to 3720 cell/cu mm, platelet count dropped to 35,000/cu mm, Activated partial thromboplastin time was prolonged (84 s), and serum procalcitonin 1.4 ng/mL. A diagnosis of septic shock was entertained and patient was shifted to intensive care unit. Imipenem was stopped and antibiotics vancomycin & clindamycin were started for Gram-positive coverage and metronidazole for anaerobic coverage as suggested by clinical microbiologist. Single donor platelet units were transfused for thrombocytopenia.\nCentral venous access was obtained via the right femoral vein. Neck veins and subclavian vein cannulation was not attempted in view of thrombosis of the left IJV. Fondaparinux was stopped in view of deranged coagulation and dropping platelet count. Inotrope in the form of noradrenaline infusion was started to maintain MAP > 65 mmHg.\nCultures of pus and devitalized tissue collected during surgery grew S. aureus sensitive to antibiotics vancomycin and clindamycin, which the patient was already receiving and blood culture was negative. No anaerobes were isolated in the specimens. Patient's condition remained stable for next 2 days after which he became progressively tachypneic and hypoxemic, with chest X-ray showing bilateral lower zone opacities. He required to be intubated and ventilated in view of persistent hypoxaemia. Over the next 3 days he made a gradual recovery. He was weaned off the inotrope and ventilator support. His platelet count improved to 379,000/cu mm, coagulation and chest X-ray normalized. After a further 3 days stay in intensive care unit, patient was discharged to ward. Throughout his stay in the hospital patient had a Glasgow coma scale 15/15 and demonstrated no neurological deficits. His further hospital course in the ward was uneventful and was discharged 3 weeks after his admission to the hospital. Oral linezolid was continued for 3wks in order to treat residual infective thrombus in the IJV.