| TITLE |
| Lemierre Syndrome Complicated by Thrombocytopenia: A Case Report |
| CASE DESCRIPTION |
| Lemierre syndrome (LS) is a rare presentation of anaerobic septicaemia originating from oropharyngeal infections, typically seen as a complication of bacterial pharyngitis or tonsillitis. Infection spreads into the lateral pharyngeal spaces and predisposes to septic thrombophlebitis of the internal jugular vein, causing significant mortality (1).A 20-year-old female with no significant history presented to the emergency department with a 3-day prodromal illness of sore throat, malaise, myalgia and back pain. Persistent tachycardia and hypotension refractory to fluid therapy necessitated a transfer to the intensive care unit. The original working diagnosis of renal colic was ruled out after a negative CTKUB and a CTPA for suspected pulmonary embolism revealed evidence of left lower zone pneumonia. Antibiotics were started however the patient remained febrile and developed a significant thrombocytopenia accompanied by acute kidney injury and derangement in liver function.On day 3, the patient developed painful reduced range of movement in the back and neck. Blood cultures grew Fusobacterium necrophorum and discussion with the microbiology team prompted consideration of LS. A CT Neck demonstrated a peritonsillar abscess with concurrent septic thrombophlebitis of the internal jugular vein (IJV) consistent with LS. Antibiotic therapy was escalated to benzylpenicillin and metronidazole in response to cultures and sensitivities.On day 10, the patient developed increasing back pain. Further imaging demonstrated evidence of pulmonary septic emboli which prompted consideration of anticoagulation.The patient eventually made a full recovery and was discharged with ongoing ENT follow-up. |
| DISCUSSION |
| This case report highlights a critically unwell young patient who was otherwise fit and healthy who had developed LS, requiring intensive care treatment. The main issue in this case was to decide whether to anticoagulate this patient in light of the symptomatic septic thrombophlebitis of the IJV. This was made more difficult by the inflammatory thrombocytopenia, making it particularly challenging to balance the risks of bleeding from introduction of anticoagulation, or further mortality from a septic embolus occluding the IJV.Upon review of the relevant literature, contrasting conclusions were found regarding routine anticoagulation (2,3) and the case was discussed with the haematology team who suggested not to start anticoagulation until the initial thrombocytopenia had resolved and to start a six-week course of rivaroxaban thereafter. This report demonstrates the aetiology, presentation, clinical progression and complexity of LS whilst highlighting the importance of communication with the wider multidisciplinary team. It also highlights the disparity in the current literature regarding routine anticoagulation in LS and identifies potential for further research in this field. |
| ACKNOWLEDGEMENTS |
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| REFERENCES |
| Wright WF, Shiner CN, Ribes JA. Lemierre syndrome. Southern Medical Journal. 2012 May;105(5):283–8. Adedeji A, Chukwura O, Obafemi T, McNulty SB, Reinert JP. Anticoagulation strategies in the management of Lemierre Syndrome: A systematic review of the literature. Annals of Pharmacotherapy. 2020 Sep 10;55(5):658–65. Gore MR. Lemierre Syndrome: A meta-analysis. International Archives of Otorhinolaryngology. 2020 Apr 24;24(03):379–85. |
