Lemierre-like syndrome after soft tissue infection due to methicillin-resistant Staphylococcus aureus: A case report and literature review

Abstract

Rationale: Lemierre-like syndrome (LLS) is characterized by bacteremia, septic thrombophlebitis of the internal jugular vein, and metastatic abscesses. In contrast to classic Lemierre syndrome, sources of infection are not related to oropharyngeal infections, as are frequent soft tissue infections. In recent years, Staphylococcus aureus has been identified as an emergent pathogen that causes this syndrome. The mortality rate of LLS caused by this pathogen is approximately 16%. Timely diagnosis, antibiotic treatment, and infection control are the cornerstones to treat LLS. Anticoagulant therapy as adjuvant treatment remains controversial.

Patient concerns: A 31-year-old woman from California, United States (US), was admitted to the emergency room with a history of 2 days of fever and severe throbbing pain in the left cervical region. Thorax and neck CT tomography revealed confluent cavities suggestive of septic embolism in the lungs and a filiform thrombus in the lumen of the left internal jugular vein, with moderate swelling of the soft and muscular tissues. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from the blood culture.

Diagnosis: The thrombus in the internal jugular vein associated with cellulitis in the neck and multiple cavitary lesions in the lungs support the diagnosis of LLS caused by MRSA with septic embolization.

Interventions: During treatment, the patient received vancomycin IV for 25 days and returned to the US with linezolid orally. In addition, assisted video-thoracoscopy and bilateral mini-thoracotomy with pleural decortication were performed for infectious source control, where 1700cc of purulent pleural fluid was drained.

Outcomes: The patient was discharged with optimal evolution.

Lessons: LLS should be suspected in patients with skin and soft tissue infections who develop thrombosis or metastatic infections. MRSA infections should be considered in patients from areas where this pathogen is prevalent.

Figure 1.

A non-contrast thoracic CT scan showed multiple bilateral nodules (red arrows) on admission.

Figure 2.

On admission, a contrast neck CT scan showed increased volume and inflammation of subcutaneous cellular tissue (white arrow) and hypodensity in the jugular vein (red arrows).

Figure 3.

On day 5th of hospitalization, a contrast thoracic CT scan showed multiple necrotic areas with confluent cavities in both lungs (red arrows) and massive pleural effusion.

Figure 4.

On day 5th of hospitalization, a neck angiography showed a hypodensity in the lumen of the left internal jugular vein, which was consistent with a filiform thrombus (red arrows).