SHM Converge Scientific Abstract ePoster Gallery-Now You See It, Now You Don't: An Unusual Presentation of Septic Thrombophlebitis

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A previously healthy 19-year-old woman presented after 6 days of worsening fever, chills, body aches, and sore throat, followed by acute respiratory distress, pleuritic chest pain, trismus, severe right neck pain, and tender cervical lymphadenopathy. Initial outpatient testing for COVID, influenza, RSV, strep, and mononucleosis was negative. In the ED, she was ill-appearing with tachycardia, hypotension, hypoxemia, crackles, and right mandibular lymphadenopathy. Early labs showed leukocytosis with bands, severe thrombocytopenia, elevated lactate, mild acute kidney injury, and respiratory alkalosis with hypoxemia.  <br /><br />Imaging on day 1 showed multifocal bilateral lower-lobe predominant lung consolidations but a patent right internal jugular vein. She was admitted to the hospital and then the ICU for septic shock and respiratory failure requiring high-flow nasal cannula. Blood cultures grew gram-negative bacilli and later identified Fusobacterium necrophorum, confirming Lemierre’s syndrome. Repeat vascular imaging on day 4 revealed a sub-occlusive right internal jugular vein thrombus, and MRI on day 5 showed intracranial extension toward the cavernous sinus.  <br /><br />Her course was complicated by pleural infection/effusion requiring IR chest tube placement and intrapleural tPA, as well as acute right-sided hearing loss. She received broad-spectrum antibiotics, later narrowed to ceftriaxone/metronidazole, and therapeutic anticoagulation with LMWH due to enlarging thrombus and intracranial concern. She improved clinically, was weaned off oxygen, chest tube was removed, and she was discharged on day 15 with a 4-week course of antibiotics and anticoagulation.  <br /><br />This case emphasizes that Lemierre’s syndrome should be suspected in young patients with fulminant sepsis and septic emboli even when initial neck imaging does not show internal jugular thrombosis.

Asset Subtitle

Catherine Liu

Meta Tag

Author List Catherine Liu, Jennifer K. Readlynn

Category Clinical Vignettes

Concept Lemierre Syndrome

Concept Sepsis

Concept Fusobacterium necrophorum

Concept Respiratory Distress

Concept Thrombophlebitis

Distinguished Non-Finalist

Presenter Organization University of Rochester School of Medicine and Dentistry

Presenting Author Catherine Liu

Track Adult

Keywords

Lemierre syndrome

Fusobacterium necrophorum

septic shock

internal jugular vein thrombosis

septic emboli

acute respiratory failure

pleural effusion

intracranial extension

cervical lymphadenopathy

antibiotic therapy

Lemierre Syndrome

Sepsis

Fusobacterium necrophorum

Respiratory Distress

Thrombophlebitis