A case of Lemierre's syndrome with septic shock and complicated parapneumonic effusions requiring intrapleural fibrinolysis

Abstract

Lemierre's syndrome is a septic thrombophlebitis of the internal jugular vein, which can lead to severe systemic illness. We report a case of an otherwise healthy 26-year-old man who suffered from pharyngitis followed by septic shock requiring intubation and vasopressor support from Fusobacterium necrophorum bacteremia. The septic emboli to his lungs caused complicated bilateral parapneumonic effusions, which recurred after initial drainage. He required bilateral chest tubes and intrapleural tPA to successfully drain his effusions. His fever curve and overall condition improved with the resolution of his effusions and after a 33-day hospitalization, he recovered without significant disability. The severity of his illness and difficult to manage complicated parapneumonic effusions were the unique facets of this case. Using an evidence-based approach of tPA and DNase for complicated parapneumonic effusions in Lemierre's syndrome can be safe and effective.

Keywords: Chest tube; Critical care; DNase, deoxyribonuclease; ED, Emergency Department; Fibrinolysis; MIST, Multicenter Intrapleural Sepsis Trial; Pleural effusion; Septic thrombophlebitis; Shock; VATS, video-assisted thoracoscopic surgery; tPA, tissue plasminogen activator.

Fig. 1

A. Axial view of a chest CT on admission showing a cavitary lesion in the left upper lobe (thick red arrow) and bilateral pleural effusions (thin blue arrows). B. Coronal view of a chest CT showing similar findings as the axial images of a cavitary left upper lobe lesion (thick red arrow) with focus on right sided consolidation (double thin blue arrows) and smaller left sided effusion (Single thin blue arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

A. Axial view of a chest CT after removal of chest tubes with evidence of resolving pleural effusions and improving areas of cavitation prior to discharge (thick red arrow). B. Coronal view of a chest CT following chest tube removal showing improvement in bilateral effusions and septic emboli. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)