Abstract
Introduction
Lemierre syndrome, also known as postanginal sepsis, is caused by Fusobacterium necrophorum . This rare disease is usually characterized by thrombophlebitis of the jugular vein and septic embolism after a history of sore throat.
Objective
Here, we discuss a case of Lemierre syndrome in a 22-year-old man with thrombophlebitis of the facial vein and fusobacteria growth in the blood culture but no obvious focus of inflammation.
Method
Case report.
Conclusion
Severe facial infection with high fever and a general feeling of malaise after a history of sore throat should raise the diagnostic possibility of facial vein thrombophlebitis due to F. necrophorum infection.
1
Introduction
Lemierre syndrome, also known as postanginal sepsis, is caused by the anaerobic Fusobacterium necrophorum . This rare disease is usually characterized by thrombophlebitis of the jugular vein and septic embolism after a history of sore throat. We discuss a case of Lemierre syndrome in a 22-year-old man with thrombophlebitis of the facial vein and fusobacteria growth in the blood culture but no obvious focus of inflammation.
2
Case
A previously healthy 22-year-old man with no medical history was admitted to the department of otorhinolaryngology, head and neck surgery, of our tertiary referral center after a 4-day history of a sore throat and generalized feeling of malaise. On day 3 of his illness, he developed a progressive, tender right facial edema with cellulitis as well as fever of 40.3°C and shivering. Examination of the oral cavity showed no signs of tonsillitis, peritonsillar abscess, or sialadenitis. The facial skin, however, showed signs of a thrombophlebitis of the right facial and angular vein ( Figs. 1 and 2 ). The blood pressure was 210/100 mm Hg; the heart rate was 130 beats per minute.
Laboratory tests showed leukocytosis (14.1 G/l [4.0–11.0]), an increased C-reactive protein serum concentration (14.9 mg/dL [<0.5]), an increased procalcitonin level (11.4 ng/mL [<0.1]), and an interleukin-6 concentration of 38.9 pg/mL (<5.9).
Ultrasound of the neck showed an abscess-like lesion in the area of the right submandibular gland. With the suspected diagnosis of submandibular abscess and in light of the deteriorating general condition of the patient, it was decided to perform a surgical drainage. Simultaneously, intravenous antibiotic therapy with clindamycin was started. Intraoperatively, the submandibular gland appeared slightly inflamed, but the actual focus of inflammation turned out to be in the right facial vein, which was affected by thrombophlebitis. Yellowish liquid was found intravascularly and sent for microbiological evaluation and culture. The thrombophlebitis did not yet reach the jugulofacial vein junction. The thrombotic facial vein was partially removed and sent to the pathology and the microbiology departments.
On computed tomography (CT), extended facial vein thrombosis was found ( Fig. 3 ), but there were no signs of thrombosis of the jugular vein, the ophthalmic vein, or the intracranial sinuses. The scan also showed extended reactive cervical lymphadenopathy. Pulmonary embolism could be excluded, but there were several infectious metastatic abscesses in both lungs ( Fig. 4 ).
Blood cultures grew Gram-negative anaerobic filamentous bacteria by day 2, which were eventually identified as belonging to the species of F. necrophorum by day 6. The patient was seen by an ophthalmologist and by a dentist, but no inflammatory focus could be found in the respective fields.
On days 1 to 5, the patient was treated with moxifloxacin, clindamycin, enoxiparin (80 mg, twice daily), and ibuprofen. First, an increase in inflammatory parameters could be observed by day 2, when the C-reactive protein level reached 27.2 mg/dL and leukocytes rose to a concentration of 17.4 G/l. From day 3 onward, however, the inflammatory parameters continually dropped. When the pathogenic agent was identified on day 6, the antibiotic treatment was continued using clindamycin combined with meropenem upon the recommendations of our bacteriologists. On day 10, the C-reactive protein level was 0.6 mg/dL and the leukocyte concentration was 6.2 G/l. It took 6 days until the facial cellulitis and edema slowly regressed ( Fig. 5 shows patient 3 weeks after hospital admission).
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