Medical Image of the Week: Central Venous Access with Dextrocardia

Figure 1. Post CVC placement chest X-ray. Catheter traced with arrows.

An 88-year old man, with known dextrocardia, was admitted with a diagnosis of septic shock. A right sided internal jugular central venous catheter was placed uneventfully using ultrasound guidance. Chest X-ray obtained after the catheter placement is shown (Figure 1). Although the utility of a chest X-ray after every ultrasound guided central line placement is questionable, it continues to be “routine practice” in many centers. In dextrocardia, a right sided central line is expected to cross the midline as in this patient. When in doubt, the catheter may not be used unless venous placement is confirmed.

Venous placement of the catheter can be confirmed by:

1. Transducing the catheter and confirming venous waveform;
2. Blood gas analysis consistent with venous gas;
3. Imaging X-ray or cross sectional (1).

Bhupinder Natt MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson, AZ USA

Reference

1. Morton PG. Arterial puncture during central venous catheter insertion. Crit Care Med. 1999 May;27(5):878-9. [CrossRef] [PubMed] 

Cite as: Natt B. Medical image of the week: central venous access with dextrocardia. Southwest J Pulm Crit Care. 2017;15(6):296. doi: https://doi.org/10.13175/swjpcc148-17 PDF 

Medical Image of the Week: Lemierre Syndrome

Figure 1. CT scan of chest (axial image) demonstrating peripheral cavitating lesion (arrow) with multifocal ground glass opacities and bilateral pleural effusions.

Figure 2. CT scan of neck, soft tissue (coronal [A], axial [B] image) demonstrating a partially occlusive thrombus in the left internal jugular vein (coronal red arrows, axial green arrow).

A previously healthy 18-year-old girl was evaluated at an urgent care center for a three day history of sore throat, fever, nausea, vomiting, diarrhea, and myalgias; the diagnosis of influenza was made at that time. Four days later, she presented to our Emergency Department with sore throat, left sided neck pain and swelling, productive cough, fever, worsening dyspnea, and pleuritic chest pain. On examination her temperature was 36.9 °C, heart rate was 142 beats per minute, and respiratory rate was 18 breaths per minute. She had enlarged tonsils without exudates, cervical and submandibular lymphadenopathy, and tenderness of her left lateral neck. Lung examination showed increased work of breathing with decreased breath sounds at the bases. Laboratory evaluation revealed an elevated white count (17,000 cells/µL) with 91% neutrophils, elevated blood urea nitrogen (21 mg/dL), creatinine (1.6 mg/dL), and venous lactate (4.0 mMol/L). Initial chest radiograph showed no evidence for acute cardiopulmonary process.  She was admitted, blood cultures were drawn, and treatment for sepsis with vancomycin, xeftriaxone, and azithromycin was initiated. Subsequent chest radiograph demonstrated an ill-defined airspace opacification in the right lower lobe.

Computed tomographic (CT) imaging of the chest showed multifocal ground glass opacities and areas of consolidation with cavitation, consistent with septic embolic disease (Figure 1). Blood cultures grew Streptococcus anginosus and Fusobacterium necrophorum. CT imaging of the neck showed a partially occlusive thrombus in the left internal jugular vein (Figure 2).  The diagnosis of Lemierre’s syndrome was made. The patient required chest tube drainage for bilateral empyema and was treated with 3 weeks of ampicillin followed by 3 weeks of high dose amoxicillin-clavulanate; she recovered completely.

Lemierre's syndrome, or anaerobic postanginal sepsis, was first described by Andre Lemierre in 1936. It is characterized by thrombophlebitis of the internal jugular vein and bacteremia caused by organisms of the normal oropharyngeal bacterial flora, classically Fusobacterium necrophorum. Lemierre’s syndrome is most commonly preceded by pharyngitis or tonsillitis, but can also be associated with odontogenic infections or otitis media. The primary infection progresses from the oropharynx and invades the lateral pharyngeal space, eventually leading to thrombophlebitis of the internal jugular vein. A majority of patients develop septic emboli, as seen in our patient, with the lungs and large joints being the most common sites of metastasis. Lemierre’s syndrome predominantly affects previously healthy children, adolescents, and young adults with most cases presenting in the second decade of life. Common physical findings include severe pharyngitis, cough/hemoptysis, dyspnea, and tenderness and swelling over the internal jugular vein. Diagnosis is confirmed by the presence of thrombophlebitis of the internal jugular vein and anaerobic organisms such as F. necrophorum in the bloodstream.

Elisa Phillips BA, BS*, Ziad Shehab MD**, and Daniela Lax MD***

*The University of Arizona College of Medicine; **Department of Pediatrics, Division of Infectious Disease; and ***Banner – University Medical Group, Pediatric Cardiology

University of Arizona

Tucson, AZ USA

References

1. Bliss SJ, Flanders SA, Saint S. Clinical problem-solving. A pain in the neck. N Engl J Med. 2004 Mar 4;350(10):1037-42. [CrossRef] [PubMed]
2. Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre's syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012 Oct;12(10):808-15. [CrossRef] [PubMed]
3. Eilbert W, Singla N. Lemierre's syndrome. Int J Emerg Med. 2013 Oct 23;6(1):40. [CrossRef] [PubMed]

Cite as: Phillips E, Shehab Z, Lax D. Medical image of the week: Lemierre syndrome. Southwest J Pulm Crit Care. 2017;15(5):223-4. doi: https://doi.org/10.13175/swjpcc135-17 PDF 

Medical Image of the Week: Post-Anginal Sepsis Syndrome

Figure 1.  Computed tomography of soft tissue of neck showing enhancing fluid density (red arrow) within the left palatine tonsil compatible with peritonsillar abscess.

Figure 2. Anterior-posterior (panel A) and lateral (panel B) of the contrast-enhanced computed tomography of soft tissue of the neck showing filling defect throughout the entire left internal jugular vein from the skull base to its insertion at the left subclavian vein consistent with total occluding thrombus (yellow arrows).

A 22-year-old woman presented to our hospital with complaints of a persistent sore throat and intermittent low grade fever associated with chills for 10 days despite 5 days of antibiotics. During this time she had also developed progressive difficulty in swallowing due to associated pain that had progressed to limited mouth opening for past 2 days. Her vital signs were normal except for low grade fever. On limited oral cavity exam bilateral tonsils appeared enlarged and erythematous; tenderness was noted on palpation of left side of the antero-lateral neck with restriction of neck movements to the left. Basic labs revealed leukocytosis (WBC of 20.2 k/mm³) but was otherwise normal. Contrast-enhanced computed tomography of soft tissue of the neck was obtained which revealed bilaterally enlarged tonsils with  small abscess within left palatine tonsil, filling defect throughout the entire left internal jugular vein from the skull base to its insertion at the left subclavian vein consistent with acute thrombosis (Figures 1 and 2). She improved considerably with intravenous antibiotics. Rapid strep test, blood and throat culture were negative. HIV, Epstein-Barr virus and cytomegalovirus antibodies were also negative. As she clinically improved we discharged her home with oral antibiotics and did not start her on anticoagulation.

Lemierre's syndrome is a septic thrombophlebitis of the internal jugular vein (IJV) commonly caused by anaerobic oro-pharyngeal flora usually by Fusobacteirum necrophorum although a wide range of bacteria may cause the syndrome (1,2). Infection is usually followed by fulminant sepsis. The infection typically originates in the palatine tonsils or peritonsillar tissue which spreads into the lateral pharyngeal space causing septic thrombophlebitis of IJV which is usually followed by distal septic embolization, resulting in multi-organ involvement with lung being the most commonly affected. Diagnosis is usually established on the presence of thrombus in IJV and a positive blood culture, but cultures can be negative in about 12 % of cases. Computed tomography of neck with contrast is the diagnostic modality of choice to demonstrate the thrombus. Prolonged course of Intravenous antibiotic (3-6 weeks) covering F. necrophorum and oral streptococci is the cornerstone of treatment. Currently there are no clear guidelines for the use of anticoagulation due to its rarity and lack of randomized controlled studies.

Chandramohan Meenakshisundaram MD, Nanditha Malakkla MD and Venu Ganipisetti, MD

Department of Internal Medicine,

Presence Saint Francis Hospital

Evanston, IL

References

1. Srivali N, Ungprasert P, Kittanamongkolchai W, Ammannagari N. Lemierre's syndrome: An often missed life-threatening infection. Indian J Crit Care Med. 2014;18(3):170-2. [CrossRef] [PubMed]
2. Pinheiro PE, Miotto PD, Shigematsu NQ, Tamashiro E, Valera FC, Anselmo-Lima WT. Lemierre's syndrome: a pharyngotonsillitis complication. Braz J Otorhinolaryngol. 2015;81(1):115-6. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N, Ganipisetti V. Medical image of the week: post-anginal sepsis syndrome. Southwest J Pulm Crit Care. 2015;11(2):66-7. doi: http://dx.doi.org/10.13175/swjpcc074-15 PDF