Abstract
Lemierre’s syndrome is a rare condition associated with infection of the oropharynx. We present an atypical case in a young healthy female who developed the condition secondary to a skin infection of the lip and chin. She also developed sepsis and chest pain. She was commenced on broad-spectrum antibiotics early and was fortunate to avoid aggressive surgical treatment. This case highlights the need for clinicians to consider this rare condition in addition to recognising its manifestations.
1
Introduction
Lemierre’s syndrome is characterised by septic thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection by anaerobic pathogens, mainly Fusobacterium species. The primary source sources of infection in the majority of cases are the palatine tonsils and peritonsillar tissues [ ]. Septic thrombophlebitis from other head and neck sources including skin infections is rare [ ]. The condition can be life-threatening with an estimated mortality of 5 %.
2
Case report
A 26-year old female presented to ED with a 2-day history of lower lip and chin swelling which initially commenced as a small spot on the chin. She had no co-morbidities. Blood investigations showed an elevated white cell count (25) and CRP (145). There was no evidence of impaired glycaemic control. Incision and drainage was undertaken under local anaesthetic, with subsequent creamy discharge and glove drains were placed ( Fig. 1 ). She was admitted and commenced on intravenous Flucloxacillin. She had worsening swelling and pain with persistent pyrexia and tachycardia the following day. Further exploration of the lip under local anaesthetic resulted in a small amount of pus being drained. She was commenced on intravenous Teicoplanin due to suspicion of developing deep skin infection. She subsequently developed chest pain. Computed tomogram of the neck ( Fig. 2 ) demonstrated a filling defect within the right anterior jugular vein, suggestive of a thrombus. Pulmonary artery angiogram ( Fig. 3 ) showed innumerable rounded areas of ground glass opacification with wedge-shaped areas of ground glass opacification in the left upper lobe, suggestive of pulmonary infarcts secondary to septic pulmonary emboli. She had further exploration of the lip with minimal debridement on day 4 post-admission. Histology showed ulcer slough and necrotic debris. Tissue culture showed presence of Staphylococcus aureus and Pseudomonas rhodesiae . The patient remained stable and was discharged after 6 days with oral antibiotics for 6 weeks and prophylactic low molecular weight heparin for 3 months. HIV screen for the patient was negative.
