Complex Lemierre syndrome with multisystemic abscesses

Abstract

We present here the challenging case of severe Lemierre syndrome in a healthy woman in her late twenties, whose clinical presentation was characterised by lung abscesses and disseminated systemic abscesses in the brain, the abdomen and the soft-tissues, as a likely consequence of a patent foramen ovale. Blood cultures were positive for Fusobacterium necrophorum and a right lingual vein thrombosis was detected at a late stage when the patient developed a septic shock. Initial antimicrobial therapy with metronidazole and ceftriaxone was modified to meropenem due to progressive worsening. The patient underwent laparoscopy and neurosurgical drainage of a cerebral abscess. She spent many days in the intensive care unit and recovered fully after 6 weeks on meropenem therapy. Although considered rare, the incidence of Lemierre syndrome, a potentially life-threatening condition, is increasing. The clinician should promptly recognise and treat it while being aware of its potential atypical presentations.

Keywords: Ear, nose and throat/otolaryngology; Infectious diseases; Intensive care; Surgery.

Figure 1

Chest CT scan showing pulmonary nodules, one of which in the right lung is excavated (yellow arrow), consistent with septic pulmonary emboli.

Figure 2

Contrast-enhanced abdominal CT scan showing a pelvic abscess (yellow arrow).

Figure 3

Contrast-enhanced neck CT scan (A) and contrast-enhanced T1-weighted MRI (B) showing a right lingual vein thrombosis (yellow arrow). In contrast, there is normal enhancement of the left lingual vein (yellow arrowhead).

Figure 4

The typical radiological features of cerebral abscess are shown in the right frontal cortex (yellow arrows): (A) hypodensity on non-contrast CT of the brain, (B) T1-weighted with contrast MR sequence and rim enhancement, (C) diffusion-weighted MR sequence showing restricted diffusion and (D) hyperintense with a hypointense rim and peripheral oedema on T2-weighted MR sequence.

Figure 5

Contrast-enhanced abdominal CT-scan showing an abscess within the right gluteus maximus (yellow arrow).