Clival osteomyelitis and hypoglossal nerve palsy--rare complications of Lemierre's syndrome

Abstract

An increasingly reported entity, Lemierre's syndrome classically presents with a recent oropharyngeal infection, internal jugular vein thrombosis and the presence of anaerobic organisms such as Fusobacterium necrophorum. The authors report a normally fit and well 17-year-old boy who presented with severe sepsis following a 5-day history of a sore throat, myalgia and neck stiffness requiring intensive care admission. Blood cultures grew F. necrophorum and radiological investigations demonstrated left internal jugular vein, cavernous sinus and sigmoid sinus thrombus, left vertebral artery dissection and thrombus within the left internal carotid artery. Imaging also revealed two areas of acute ischaemia in the brain, consistent with septic emboli, skull base (clival) osteomyelitis and an extensive epidural abscess. The patient improved on meropenem and metronidazole and was warfarinised for his cavernous sinus thrombosis. He has an on-going left-sided hypoglossal (XIIth) nerve palsy.

Figure 1

MRI of the head showing extensive high signal at the skull base consistent with skull base osteomyelitis. Filling defect in left vertebral artery (red arrow) consistent with thrombosis. Note the normal opacification of the right vertebral artery (block green arrow).

Figure 2

MRI of the head showing filling defects within the left cavernous sinus (red arrow) and sigmoid sinus (green arrow) consistent with thrombosis.