An Atypical Presentation of Lemierre's Syndrome: Complicated by Thrombotic Thrombocytopenic Purpura

Abstract

Lemierre's syndrome is an oropharyngeal infection complicated by septic thrombophlebitis of the internal jugular vein, bacteremia, and septic emboli. It mainly occurs in immunocompetent individuals and was first reported in the early 1900s by physician Andre Lemierre. A 23-year-old male presented to our institution with sore throat, difficulty swallowing, left-sided ear pain, nausea, vomiting, subjective fevers, general malaise, right-sided rib pain, and anorexia. Complete blood cell count and metabolic panels revealed severe thrombocytopenia, mild anemia, acute kidney injury, and hyperbilirubinemia. Blood cultures grew Fusobacterium necrophorum. Ultrasound and computed tomography scan of the neck revealed thrombosis of the left internal jugular vein. ADAMTS13 activity was later reported to be markedly decreased at less than 2%, confirming a diagnosis of thrombotic thrombocytopenic purpura.

Keywords: fusobacterium necrophorum; lemierre; lemierre's; lemierre's syndrome; thrombocytopenia; thrombotic thrombocytopenic purpura.

Figure 1. Chest radiograph showing scattered, non-calcified pulmonary nodules.

Figure 2. Reformatted CT chest without contrast showing right-sided loculated pleural effusion (red arrow) and left-sided cavitary lung nodule (yellow arrow) prior to pigtail catheter placement.

CT, computed tomography

Figure 3. Neck ultrasound showing left internal jugular vein thrombosis (red arrow).

Figure 4. CT neck with contrast (sagittal view) showing filling defect of the left internal jugular vein (red arrow).

CT, computed tomography

Figure 5. TEE showing an echodensity in the aortic root (red arrow).

TEE, transesophageal echocardiogram

Figure 6. Reformatted CT chest without contrast and with pigtail catheter. Pigtail catheter (orange arrow) and resolving pleural effusion on the left following TPA administration.

TPA, tissue plasminogen activator