Forgotten disease: an atypical case of Lemierre syndrome presenting as a soft tissue abscess

Abstract

Lemierre syndrome (LS) is an acute oropharyngeal infection with secondary septic thrombophlebitis and distant septic embolisation. A 29-year-old woman with sore throat, dyspnoea and left shoulder pain, who was on levofloxacin for 3 days, presented with worsening symptoms. She was tachycardic, tachypneic and hypoxic on presentation. CT of neck and chest revealed multiple loculated abscesses on her left lower neck and shoulder, right peritonsillar abscess, thrombosis of the right external jugular vein and multiple bilateral septic emboli to the lungs. She was started on clindamycin and ampicillin sulbactam for LS. She developed septic shock and required intubation due to respiratory failure. Drainage of the left shoulder abscess grew Fusobacterium nucleatum After 2 weeks of a complicated intensive care unit stay, her haemodynamic status improved and she was transferred to the floor. LS has variable presentations, but regardless of the presentation, it is a potentially fatal disease-requiring prompt diagnosis and management.

Keywords: adult intensive care; ear; infectious diseases; nose and throat/otolaryngology; pleural infection; pulmonary embolism.

Figure 1

CT scan of the chest with contrast illustrates multiple scattered nodularities suspicious of septic emboli in both lungs and a mild loculated bilateral pleural effusion.

Figure 2

CT soft tissue of the neck with intravenous contrast. (A) Extensive and severe soft tissue swelling at left lateral neck base with a 7 cm thick-walled loculated fluid collection concerning for abscess demonstrated by white arrows. (B) Transverse view of soft tissue neck demonstrates patent bilateral internal jugular veins with a 1.6 cm x 0.6 cm right peritonsillar abscess (demonstrated by white arrows) and thrombosed right external jugular vein (demonstrated by blue arrow).