3. Discussion
Our case presents a complicated patient with Lemierre Syndrome with
septic shock secondary to Fusobacterium nucleatum with most
sequelae involving osteomyelitis, multi-organ abscesses, pericardial
effusion, and bilateral pleural effusions secondary to bilateral
necrotizing pneumonia (left>right) with lung abscesses.
Although the patient presented with presumed streptococcal pharyngitis
due to exposure to college friends, it is imperative to swab and test
patient before antibiotic administration. As the patient returned with
continued fevers and worsening of symptoms, the suspicion for Lemierre’s
syndrome is reasonable given patient’s age group and deteriorating
respiratory status. However, it is not unreasonable to be suspicious for
multisystem inflammatory syndrome in children (MIS-C) as well
considering the era of SARS-CoV-2 23. Serologic
inflammatory markers also make LS highly likely20. Of
note, LS can also present as sinusitis or mastoiditis in young adults,
and approximately 75% of patients are male. Those affected are young
individuals who are usually immunocompetent without serious
comorbidity1. The patient’s thromboembolic
complications were not identified on any imaging studies; however,
improvement with antibiotics, thoracentesis, VATS, and pleural fluid
drained by chest tubes indicate that the etiology of medical condition
to be suspicious for LS.
Due to Fusobacterium nucleatum’ s ubiquitous nature as normal
flora in many healthy individuals’ oropharyngeal, gastrointestinal, and
genitourinary tracts, it is imperative to obtain a history of the
patient’s onset of symptoms. Our patient traveled to another state to
visit friends, attended several social events, and shared utensils with
multiple persons. Furthermore, the patient had dental work done
approximately two months prior to onset of symptoms. With the initial
onset of pharyngitis after her trip in the context of dental work and
cleaning, patient may demonstrate weakened host mucosal barriers,
allowing commensal organisms such as Fusobacterium nucleatum to
disseminate into her bloodstream. Reported risk factors forFusobacterium bacteremia include immunosuppression, alcohol
abuse, malignancy, older age, dialysis, and hospital
acquired21. Moreover, Fusobacterium nucleatumhas been shown to be associated with liver
involvement26, explaining patient’s scleral icterus
bilaterally, which may have caused her vision to be temporarily bright
and blurry in the ER18.
Our patient’s outside hospital admission included blood cultures, which
successfully identified Fusobacterium nucleatum as the source of
her infection. This pathogen may take up to 5-8 days to culture
stressing the importance to administer empiric antibiotics with
anaerobic coverage and varied diagnostic studies. Additionally, early
detection of the pathogen is imperative to foster favorable prognosis.
The rapid administration of treatment depends on the clinician’s
awareness of LS and considering it as a differential diagnosis. It is
not unreasonable to suspect LS in any young adult who presents with
ongoing fevers in the recent episode of pharyngitis, even when source is
unknown or presumed like streptococcus pyogenes .
Literature shows other patients with Lemierre’s syndrome have presented
with severe sepsis and abdominal pain, treated with
ampicillin-sulfabactum and metronidazole intravenously for three weeks,
followed by a three-week course of oral amoxicillin/clavulanate,
intravenous hydration, inotropic support, and thoracostomy tube drainage
of pleural effusion12. Lack of characteristic neck
symptoms or a negative initial neck ultrasound exam does not rule out
LS.6 Case studies have demonstrated metastatic
infections in the lung and brain including meningitis requiring
aggressive management and therapies5, 19, 26. Another
case study demonstrated patient with LS showing septic arthritis of
right shoulder, as well as parapharyngeal abscess extending from base of
skull to thoracic inlet, complicated by right IJV and subclavian vein
thrombosis, and multiple lung emboli. Patient improved with oral
clindamycin and metronidazole, IV gentamicin, IV piperacillin and
tazobactam, incision and drainage of parapharyngeal abscess, and drain
left in-situ13.
There are few case reports out of Belgium that reportFusobacterium as a possible complication of COVID-19 virus, as
none of the patients had any risk factors for F. nucleatumbacteremia. All patients were adults with other comorbid
factors21. They were tested COVID PCR positive for
SARS-CoV-2, which resulted in digestive tract invasion and hence leading
to Fusobacterium bacteremia21. Other organisms
besides Fusobacterium necrophorum can cause LS such asStreptococcus , Proteus , Bacteroides ,
and Peptostreptococcus . In this particular case report, patient
had severe respiratory and renal involvement without thrombosis of the
jugular vein similar to our case22.
Lastly, it is imperative to not delay seeking medical attention due to
concerns about the SARS-CoV-2 outbreak, as one patient with delayed care
presented with atypical Lemierre’s syndrome involving the brain, liver,
and lungs following a dental infection, ultimately resulting in serious
and complex sequelae26.