Date Published: October 20, 2017
Publisher: John Wiley and Sons Inc.
Author(s): Laura Garcia, Kaori Ito.
Lemierre’s syndrome is a rare clinical condition that is characterized by infected internal jugular vein thrombosis with metastatic septicemia. The most common causative agent is Fusobacterium necrophorum. A previously healthy 37‐year‐old woman presented to our emergency department with nausea, vomiting, and diarrhea. She was admitted to the general practice unit with a diagnosis of acute pancreatitis then was subsequently transferred to the intensive care unit due to shock. Physical examination revealed tenderness on right side of the neck. Blood cultures were remarkable for F. necrophorum. Clinical symptoms led to subsequent ultrasound and computed tomography scan of the neck, confirming internal jugular vein thrombosis.
The patient was treated with antibiotics for 6 weeks. Anticoagulation therapy was initiated.
We report a case of Lemierre’s syndrome that presented as acute pancreatitis. The high index of suspicion of this disease is important for early diagnosis.
Lemierre’s syndrome (LS) is a septic thrombophlebitis of the internal jugular vein (IJV) caused by anaerobic bacteria, most commonly a Gram‐negative, non‐spore‐forming obligate anaerobic bacterium known as Fusobacterium necrophorum, which is part of the normal oral flora.1 Typical symptoms are sore throat, lateral neck pain, pulmonary symptoms, and fever. Next, there is invasion of the lateral pharyngeal wall and thrombophlebitis of the internal jugular vein. This is then followed by bacteremia and septic emboli to vital organs, which can lead to metastatic abscesses, as well as other fatal complications.2, 3, 4
A 37‐year‐old African American healthy immunocompetent woman presented to an emergency department with chief complaints of abdominal pain, anorexia, cough, nausea, vomiting, and diarrhea for 5 days. She admitted to tobacco use, drinking two to three alcoholic drinks two to three times per week, and denied substance abuse. Of note, the patient had not been drinking alcohol for the week prior to her presentation due to feeling unwell. Review of systems was significant for neck pain, productive cough with blood tinged sputum, fatigue, diffuse abdominal pain, nausea, vomiting, and diarrhea. Her vital signs were normal except for tachycardia (heart rate, 110 b.p.m.). On physical examination, she had diffuse tenderness to palpation on abdomen. Laboratory tests were significant for leukocytosis with bandemia (16.7 K/μL, band 15%) and elevated lipase (>2,250 IU/L). Ultrasound of the abdomen was unremarkable. Computed tomography (CT) of the abdomen and pelvis was significant for pancreatitis with a small amount of ascites (Fig. 1). Based on these findings, patient was diagnosed with acute pancreatitis. At this point, the etiology of pancreatitis was unclear because the patient had not had alcohol for 1 week. She was transferred for admission to a general medical unit for the treatment of acute pancreatitis with unknown etiology.
Named after Andre Lemierre’s initial report in 1936,1 LS continues to be a clinical challenge for early diagnosis due to its various manifestations secondary to metastatic septic emboli. It is a very rare entity as there have been less than 160 published cases since his case series.2
We reported a case of LS complicated with acute pancreatitis potentially caused by metastatic septic emboli. Oropharyngeal symptoms were the early indicator of LS despite prominent symptoms of acute pancreatitis. Therefore, it is important to have a high index of suspicion for early diagnosis and appropriate treatment.
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