Gastrointestinal variant of Lemierre's syndrome complicating ruptured appendicitis

Abstract

Fusobacterium necrophorum is a non-spore-forming, obligate anaerobic, filamentous, gramnegative bacillus that frequently colonizes the human oral cavity, respiratory tract, and gastrointestinal tract. Fusobacterium species have rarely been implicated in cases of gastrointestinal variant of Lemierre's syndrome. We describe a case of F. necrophorum bacteremia associated with suppurative porto-mesenteric vein thrombosis (PVT) following acute ruptured appendicitis. In addition, we list the documented twelve cases of Fusobacterium pylephlebitis. Recanalization of the porto-mesenteric veins and relief of the extrahepatic portal hypertension were achieved with early empiric antibiotic and local thrombolytic therapy. Our patient's case underscores the importance of recognizing Fusobacterium bacteremia as a possible cause of suppurative PVT after disruption of the gastrointestinal mucosa following an acute intraabdominal infectious process. Early treatment of this condition using anticoagulation and endovascular thrombolysis as adjunctive therapies may prevent PVT complications.

Keywords: Fusobacterium necrophorum; Lemierre's syndrome; Local thrombolytic therapy; Porto-mesenteric vein thrombosis; Pylephlebitis.

Fig. 1

A computerized axial tomography (CAT scan) of the abdomen and pelvis with intravenous contrast and ultrasound Doppler studies showed splenomegaly with acute thrombosis of the proximal main portal vein at the confluence of the superior mesenteric vein (SMV) and splenic vein. No hepatic abnormalities were identified to suggest cirrhosis, infarct, abscess or cavernous transformation.

Fig. 2

Venography revealed the presence of cavernous transformation of the portal vein.

Fig. 3

Transhepatic endovascular thrombolysis was attempted to mitigate the thrombotic disease, and was successful in recanalizing the porto-mesenteric veins.