A Rare Case of Culture-negative Lemierre’s Syndrome with Septic Pulmonary Emboli

Authors' Affiliations

J. Maddex Webb, Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

Location

D.P. Culp Center Ballroom

Start Date

4-5-2024 9:00 AM

End Date

4-5-2024 11:30 AM

Poster Number

63

Name of Project's Faculty Sponsor

S. Brock Blankenship

Faculty Sponsor's Department

Medical Education

Classification of First Author

Clinical Doctoral Student

Competition Type

Competitive

Type

Poster Presentation

Presentation Category

Health

Abstract or Artist's Statement

Lemierre's syndrome, also known as infectious thrombophlebitis of the internal jugular vein, typically arises from extension of oropharyngeal infections. Frequently caused by anaerobic bacteria like Fusobacterium necrophorum, this condition may lead to serious complications such as bacteremia, septicemia, and notable septic emboli often found migrating to the lungs, resulting in cavitary lesions. Treatment generally involves prolonged antibiotic therapy, and in certain instances, anticoagulation is necessary to manage thrombosis. Predominantly affecting young, otherwise healthy adults, Lemierre's syndrome carries a high mortality rate if left untreated. In our case, a 27-year-old female without significant medical history presented to a rural ED with a severe sore throat, fever, nausea, and chest pain lasting five days. Despite starting outpatient amoxicillin treatment three days after symptom onset, her condition worsened, evidenced by increasing chest pain and general malaise. Upon presentation, she was febrile (101.5°F), tachycardic (HR 121 bpm), with normal BP (126/80 mmHg) and oxygen saturation (98% on room air). Examination revealed a systolic murmur, rhonchi, and trace bilateral lower extremity edema. Laboratory analysis showed leukocytosis (WBC 12.8 x 10^3/μL, 84% neutrophils), elevated CRP (184.3 mg/L), ESR (60 mm/hr), and D-dimer (2560 ng/mL). A chest CT scan suggested multifocal septic pulmonary emboli, leading to her transfer to a larger center for further workup and infectious disease consultation. She received initial empiric IV therapy with vancomycin and piperacillin/tazobactam, which was later de-escalated to ceftriaxone. A neck CT showed internal jugular vein thrombophlebitis and suspicious lymphadenopathy, characteristic of Lemierre's syndrome, explaining the septic emboli. Despite no cardiac vegetations found on transthoracic echocardiography and negative blood and respiratory cultures, Bartonella quintana IgM serologies returned positive post-discharge, marking a recent infection with this aerobic, gram-negative bacterium. In the majority of cases, blood cultures identify the etiologic source; however, reported cases of culture-negative Lemierre’s syndrome do exist. In this case, Lemierre's syndrome was atypically associated with Bartonella quintana, a novel finding since Bartonella species have not been previously implicated in this condition to our knowledge. Interestingly, Bartonella species are known for their role in culture-negative endocarditis. While Fusobacterium necrophorum and other anaerobes are typically associated with Lemierre's, the potential involvement of Bartonella quintana here broadens the spectrum of etiological agents. This emphasizes the necessity for comprehensive serological testing when culture methods fail. Understanding this potential association is crucial, as it may influence both the empirical antibiotic strategy and the overall management of similar cases.

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Apr 5th, 9:00 AM Apr 5th, 11:30 AM

A Rare Case of Culture-negative Lemierre’s Syndrome with Septic Pulmonary Emboli

D.P. Culp Center Ballroom

Lemierre's syndrome, also known as infectious thrombophlebitis of the internal jugular vein, typically arises from extension of oropharyngeal infections. Frequently caused by anaerobic bacteria like Fusobacterium necrophorum, this condition may lead to serious complications such as bacteremia, septicemia, and notable septic emboli often found migrating to the lungs, resulting in cavitary lesions. Treatment generally involves prolonged antibiotic therapy, and in certain instances, anticoagulation is necessary to manage thrombosis. Predominantly affecting young, otherwise healthy adults, Lemierre's syndrome carries a high mortality rate if left untreated. In our case, a 27-year-old female without significant medical history presented to a rural ED with a severe sore throat, fever, nausea, and chest pain lasting five days. Despite starting outpatient amoxicillin treatment three days after symptom onset, her condition worsened, evidenced by increasing chest pain and general malaise. Upon presentation, she was febrile (101.5°F), tachycardic (HR 121 bpm), with normal BP (126/80 mmHg) and oxygen saturation (98% on room air). Examination revealed a systolic murmur, rhonchi, and trace bilateral lower extremity edema. Laboratory analysis showed leukocytosis (WBC 12.8 x 10^3/μL, 84% neutrophils), elevated CRP (184.3 mg/L), ESR (60 mm/hr), and D-dimer (2560 ng/mL). A chest CT scan suggested multifocal septic pulmonary emboli, leading to her transfer to a larger center for further workup and infectious disease consultation. She received initial empiric IV therapy with vancomycin and piperacillin/tazobactam, which was later de-escalated to ceftriaxone. A neck CT showed internal jugular vein thrombophlebitis and suspicious lymphadenopathy, characteristic of Lemierre's syndrome, explaining the septic emboli. Despite no cardiac vegetations found on transthoracic echocardiography and negative blood and respiratory cultures, Bartonella quintana IgM serologies returned positive post-discharge, marking a recent infection with this aerobic, gram-negative bacterium. In the majority of cases, blood cultures identify the etiologic source; however, reported cases of culture-negative Lemierre’s syndrome do exist. In this case, Lemierre's syndrome was atypically associated with Bartonella quintana, a novel finding since Bartonella species have not been previously implicated in this condition to our knowledge. Interestingly, Bartonella species are known for their role in culture-negative endocarditis. While Fusobacterium necrophorum and other anaerobes are typically associated with Lemierre's, the potential involvement of Bartonella quintana here broadens the spectrum of etiological agents. This emphasizes the necessity for comprehensive serological testing when culture methods fail. Understanding this potential association is crucial, as it may influence both the empirical antibiotic strategy and the overall management of similar cases.