Chest-1997-Venkataraman-268-70 by xiaohuicaicai


									           Fever, Sore Throat, and Pulmonary
           Infiltrates in a 20-Year-Old Man
           Mythili T. Venkataraman and Maurice Policar

           Chest 1997;112;268-270
           DOI 10.1378/chest.112.1.268
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                   pulmonary and critical care pearls
                   Fever, Sore Throat, and Pulmonary
                   Infiltrates in                a   20-Year-Old Man*
                   Mythili T. Venkataraman, MBBS, FCCP; and Maurice Policar, MD

                             (CHEST 1997; 112:268-70)
 \ 20-year-old Vietnamese man was admitted to the
-^- hospital with fever and
                         pharyngitis. to had been
in excellent health until 5
                          days prior admission.
His illness began with a sore throat, accompanied by
fever, chills, arthralgia, and headache. He was seen
in the Emergency Department a day prior to admis¬
sion and was treated with intramuscularly adminis¬
tered penicillin for presumed streptococcal pharyn¬
gitis, but symptoms persisted. The patient had been
in the United States for 5 years. There was no history
of recent travel or of rheumatic fever. The patient
said that he had been sexually promiscuous, but
denied intravenous drug use.
Physical Examination
  The patient appeared ill. Vital signs included a
temperature of 40°C; heart rate, 110 bpm; respira¬
tory rate,22 breaths
                   per min; and BP,  90/65 mmHg.
Examination of the ears, nose, and throat showed                Figure 1. Chest x-ray film   showing bilateral nodular infiltrates
pharyngeal erythema and bilateral exudative tonsil¬
litis. The neck was supple with no lymphadenopathy.
Cardiac exam revealed tachycardia. The lungs were               lymphocytes); hemoglobin, 12.3 g/dL; and platelet
clear. Examination of the abdomen, extremities, and             count, 21,000/mm3. A peripheral blood smear
neurologic system revealed no abnormalities.                    showed toxic granulations, hypochromia, and throm¬
Laboratory Examination                                          bocytopenia. Electrolyte values and results of liver
                                                                and renal function tests were within normal limits. A
  Laboratory values were as follows: WBC, 17,000/               disseminated intravascular coagulation panel showed
mm (84% polymorphonuclear leukocytes and 7%                     no abnormalities. Arterial blood gas values (patient
                                                                breathing room air) were pH, 7.44; Pco2, 32 mm Hg;
*From the Mount Sinai Services, Elmhurst     Hospital Center,   and Po2, 67 mm      Hg. A chest x-ray film is shown in
Elmhurst,    NY.
                                                                Figure      1.
Manuscript received June 20, 1996; revision accepted Septem¬
ber 17.
Reprint requests: Sinai Venkataraman, Division of Pulmonary
                  Dr.                                           What is the diagnosis?
Medicine, Mount          Services.Elmhurst Hospital Center.
E6-27A, 79-01 Broadway, Elmhurst, NY 11373                      How would you proceed with therapy?

268                                                                                              Pulmonary and Critical Care Pearls

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                                 1997 by the American College of Chest Physicians
Diagnosis: Lemierre's syndrome.postanginal sepsis
due to anaerobic oropharyngeal infection or
necrobacillosis with septic thrombophlebitis of the
internal jugular vein and multiple pulmonary emboli.
   Lemierre's syndrome is a rare form of postanginal
sepsis usually caused by Fusobacterium infection. It
was first described in detail by Lemierre in 1936. It
is characterized by acute oropharyngeal infection,
suppurative thrombophlebitis of the internal jugular
vein, sepsis, and metastatic complications, the most
common being septic pulmonary emboli. It may be
confused with right-sided endocarditis.
   Lemierre's syndrome was a fatal suppurative dis¬
ease before the advent of antibiotics. Although ton¬
sils are the usual primary source of infection, cases
resulting from otitis, parotitis, and mastoiditis also
have been described. ARDS has been reported as a
complication of this syndrome. Metastatic complica¬
tions, besides septic pulmonary emboli, include em-
pyema, pericarditis, septic arthritis, liver abscess, and
meningitis. Thrombophlebitis of the internal jugular
vein, the hallmark of this syndrome, may be clinically
occult or present with neck pain, swelling, and the         Figure 2. CT scan of the neck showing thrombosis of the
"cord sign" (palpable induration of the internal jug¬       internal jugular vein.
ular vein). Spread of infection may occur via peri-
tonsillar veins, the jugular lymphatic system, or by
direct spread. A CT scan of the neck with contrast
medium is the most appropriate study, although
ultrasound has been suggested.
                                                            CT   scan (Fig 2) showed thrombosis of the internal
   F necrophorum is the pathogen in the majority of         jugular vein on theright side. The patient underwent
                                                            an emergency ligation of the right internal jugular
reported cases. It is a long, spindle-shaped, Gram-         vein. Postoperatively, he continued to have fever
negative anaerobic bacillus. It has the ability to be an    despite antibiotic therapy, but gradually showed
invasive pathogen in otherwise healthy subjects.
Other organisms may be involved as well.                    clinical improvement with resolution of symptoms
  Treatment depends on the severity of infection.           and septic emboli. The platelet count improved with
Intravenously administered antibiotics directed at          therapy. The organism growing in the blood cultures
anaerobic microbes (ie, clindamycin, penicillin, am-        was identified as F necrophorum.

picillin-sulbactam, metronidazole, ticarcillin-clavu-
lanate) effective patients without metastatic
        are           in
infections. If signs of sepsis persist with propagation                        Clinical Pearls
of infection, ligation or excision of the internal
jugular vein use required. There is no documented
               is                                             1. Lemierre's   syndrome is characterized by sup¬
role for the      of anticoagulation therapy.               purative thrombophlebitis of the internal jugular
   The present patient was initially treated with           vein associated with oropharyngeal infection, the
cefuroxime for tonsillitis and bacterial pneumonia          most common being tonsillitis.
but continued to have fever. On hospital day 2, the           2. Usually it is caused by anaerobic infections,
antibiotic therapy was changed to penicillin and
metronidazole. Blood cultures were suggestive of
                                                            especially F necrophorum ("necrobacillosis").
                                                               3. It is commonly associated with septic pulmo¬
anaerobic bacteria, but identification was pending.         nary emboli, occasionally with distant abscesses.
On hospital day 3, crackles were noticed at the time           4. ACT scan of the neck with contrast medium is
of lung examination, and the patient was transferred        the imaging modality of choice.
to the ICU. A chest radiograph showed bilateral                5. Treatment consists of TV administration of
nodular infiltrates of varying sizes that were consis¬      high-dose antibiotics that have anaerobic activity.
tent with septic emboli (Fig 1). Therapy with ampi-            6. Persistent sepsis and emboli despite the use of
cillin-sulbactam was initiated. Although physical ex¬       antibiotic therapy is an indication for ligation or
amination of the neck revealed no abnormalities, a          excision of the internal jugular vein.

                                                                                        CHEST/112/1 /JULY, 1997       269

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                               1997 by the American College of Chest Physicians
                Suggested Readings                                             forgotten disease. BMJ 1984; 288:1526-27
                                                                             Moreno S, Altozano    JG, Pinilla B, et al. Lemierre's disease:
Cosgrove EF, Coldny SM, Pesce RR. Adult respiratory distress                   postanginal bacteremia and pulmonary involvement caused by
  syndrome as a complication of postanginal sepsis. Chest 1993;                Fusobacterium necrophorum. Rev Infect Dis 1989; 2:319-24
                                                                             Sinave CP, Hardy GJ, Fardy PW. The Lemierre syndrome:
Hughes CE, Spear RK, Shinabarger CE, et al. Septic pulmonary                   suppurative thrombophlebitis of the internal jugular vein
  emboli complicating mastoiditis: Lemierre's syndrome revis¬
  ited. ClinInfect Dis 1994; 18:633-35                                         secondary to oropharyngeal infection. Medicine 1989; 68:85-94
Lemierre A. On certain septicaemias due to anaerobic organisms.              Tovi F, Fliss DM, Noyek AM. Septic internal jugular vein
  Lancet 1936; 1:701-03                                                        thrombosis. J Otolaryngol 1993; 22(6):415-20
Lustig LR, Cusick BC, Cheung SW, et al. Lemierre's syndrome:                 Vogel LC, Boyer KM. Metastatic complications of Fusobacterium
  two cases   of postanginal     sepsis. Otolaryngol Head Neck Surg            necrophorum sepsis. AJDC 1980; 134:356-58
  1995; 112:767-72                                                           Weesner CL, Cisek JE. Lemierre syndrome: the forgotten
Moore-Gillon    J,   Lee   TH,   Eykyn SJ,   et   al. Necrobacillosis:   a     disease. Ann Emerg Med 1993; 22:256-58

270                                                                                                          Pulmonary and Critical Care Pearls

                            Downloaded from by guest on October 25, 2011
                                      1997 by the American College of Chest Physicians
  Fever, Sore Throat, and Pulmonary Infiltrates in a 20-Year-Old Man
              Mythili T. Venkataraman and Maurice Policar
                         Chest 1997;112; 268-270
                      DOI 10.1378/chest.112.1.268
             This information is current as of October 25, 2011
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