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: Septic Emboli

Figure 1. Panels A-F: Selected static images from the thoracic CT showing numerous septic pulmonary emboli with cavitation. Lower panel: movie of selected images from thoracic CT scan.

A 46-year-old man was admitted with altered mental status. His past medical history included HIV/AIDS on HAART therapy, hepatitis B and C, non-Hodgkin's lymphoma (NHL), deep venous thrombosis with insertion of an inferior vena caval filter, and poly-substance abuse. Vitals revealed fever and tachycardia. On exam, he was lethargic and confused, and had bilateral crackles on lung auscultation. Computerized axial tomography (CT) of the head was unremarkable and chest X-ray revealed patchy nodular infiltrates in the right upper lobe and bilateral lower lobes. Work up for an infectious cause was initiated including opportunistic infections and he was started on empiric antibiotics for pneumonia. On Day 2, his roommate who came to visit him, revealed that he was recently admitted in another hospital for headache and flu-like symptoms, and discharged with a peripherally inserted central catheter (PICC) in place as he was scheduled for a positron emission tomography (PET) the next morning for evaluation of recurrence of NHL. However, he presented for the PET scan 10 days after discharge, during which period he was abusing heroin through the PICC line. A thoracic CT was also obtained which showed innumerable scattered cavitary pulmonary opacities with peripheral ground glass opacities consistent with septic pulmonary emboli in the right and left upper lobe and right middle lobe (Figure 1). Blood and urine cultures grew methicillin-resistant Staphylococcus aureus, CD4 count was 180, cryptococcus and histoplasma antigens were negative, as were urine antigens for pneumococcus and legionella. He was also found to have deep venous thrombosis of the right upper extremity. Trans-esophageal echocardiogram was negative for valvular vegetations. He was successfully treated with vancomycin and rifampin and discharged home.

Septic pulmonary emboli are embolization of infectious particles into the lungs via the pulmonary arterial system. Septic pulmonary emboli can occur from varying sources. Patients may be asymptomatic or present with sepsis. CXR shows multiple nodules in the periphery of the lower lobes. CT chest may show feeding vessel sign (a vessel coursing directly to a nodule or mass) in 50% of patients. Early diagnosis and prompt treatment can lead to a successful outcome.

Nanditha Malakkla MD and Chandramohan Meenakshisundaram MD

St. Francis Hospital

Evanston, IL

References

1. Fidan F, Acar M, Unlu M, Cetinkaya Z, Haktanir A, Sezer M. Septic pulmonary emboli following infection of peripheral intravenous cannula. Eur J Gen Med. 2006;3:132–5.
2. Kuhlman JE, Fishman EK, Teigen C. Pulmonary septic emboli: Diagnosis with CT. Radiology. 1990;174:211–3. [CrossRef] [PubMed]
3. Hind CR. Pulmonary complications of intravenous drug misuse. 1. Epidemiology and non-infective complications. Thorax 1990; 45:891-8. [CrossRef] [PubMed]

Reference as: Malakkla N, Meenakshisundaram C. Medical image of the week: septic emboli. Southwest J Pulm Crit Care. 2014;9(3):183-4. doi: http://dx.doi.org/10.13175/swjpcc120-14 PDF 

Medical Image Of The Week: Septic Pulmonary Emboli Misdiagnosed As Metastatic Disease

Figure 1. Representative thoracic CT axial images showing multiple pulmonary nodules (red arrows).

A 54-year-old previously healthy man presented with acute onset of left-sided, sharp pleuritic chest pain and dry cough. He denied having fever, hemoptysis, shortness of breath, or unintentional weight loss. Review of system was positive for bright blood per rectum for the last year. He had a root canal procedure done 3 weeks prior to presentation. His is a 30 pack-year smoker, drinks alcohol occasionally, but denied any IV drug use.

On admission, he was afebrile and hemodynamically stable. Clinical examination was positive for fecal occult blood test. CBC revealed WBC of 12,800/mm³ and his hemoglobin was11.9 g/dL. Thoracic CT scan with contrast was negative for pulmonary embolism, but showed multiple bilateral pulmonary nodules suspicious for malignancy (Figure 1). The left upper lobe showed a subpleural 2.4 x 1.5 cm rounded opacity and emphysematous changes. CT of the abdomen and pelvis showed folds in the stomach but was otherwise unremarkable.

Esophagogastroduodenoscopy was negative. Colonoscopy showed non-bleeding internal hemorrhoids. He underwent percutaneous CT guided lung biopsy. Pathology report showed distended alveoli filled with polymorphonuclear leukocytes mixed with fibrin consistent with septic emboli and no evidence of malignancy.  Special stains for organisms were negative. Blood cultures were negative, Trans-esophageal echocardiograph was normal. Mandibular film done was negative for dental abscess. HIV serology, Quantiferon gold, ß-d glucan, Aspergillus, and mycobacterial culture of sputum were negative. During his hospital stay he developed a fever and his WBC count increased. He was empirically started on broad spectrum antibiotics and he clinically improved significantly.

Septic pulmonary embolus (SPE) is a serious and uncommon condition that poses a diagnostic challenge and carries a high mortality (1,2). Presenting symptoms are often non-specific. Blood cultures may be negative initially. Similarly, chest radiography is not helpful to establish a diagnosis. CT is more useful, usually showing multiple peripheral nodular opacities. SPE can be suspected by the presence of potential source of underlying infection, febrile illness and multiple pulmonary nodules.

Dima Dandachi MD and Sathish Krishnan MD

Department of Internal Medicine

Saint Francis Hospital

Evanston, IL

References

1. Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: a systematic review. Respir Med 2014;108(1):1-8. [CrossRef] [PubMed]
2. Shiota Y, Taniguchi A, Yuzurio S, Horita N, Hosokawa S, Watanabe Y, Tohmori H, Ono T; Okayama Respiratory Disease Study Group. Septic pulmonary embolism induced by dental infection. Acta Med Okayama. 2013;67(4):253-8. [PubMed] 

Reference as: Dandachi D, Krishnan S. Medical image of the week: septic pulmonary emboli misdiagnosed as metastatic disease. Southwest J Pulm Crit Care. 2014;9(1):38-9. doi: http://dx.doi.org/10.13175/swjpcc083-14 PDF

Medical Image of the Week: Septic Emboli from Elbow Abscess

Figure 1. Panel A: Multiple thick wall cavities. Panel B: pneumothorax (arrows).

A 45 year old man with past medical history of rheumatoid arthritis and intravenous drug use presented with a several week history of progressive right elbow pain. He underwent incision and drainage with an operative diagnosis of septic arthritis.  He developed postoperative respiratory failure requiring prolonged mechanical ventilation.  Wound and blood cultures grew methacillin-resistant Staphylococcus aureus.  CT Chest revealed multiple thick walled cavities (A) from septic emboli as well as rupture of a pneumatocele causing a pneumothorax (B, arrows) necessitating chest tube insertion.

John F. Rosell, MD, Janet Campion, MD and Philip Factor, DO

Departments of Medicine and Emergency Medicine

University of Arizona

Tucson, AZ

Reference as: Rosell JF, Campion J, Factor P. Medical image of the week: septic emboli from elbow abscess. Southwest J Pulm Crit Care. 2013;7(1):27. doi: http://dx.doi.org/10.13175/swjpcc088-13 PDF

April 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

A 38-year old man presented to the Emergency Department with complaints of chest pain, shortness of breath, and fever. A frontal chest radiograph (Figure 1A) was performed; a comparison chest radiograph (Figure 1B) is presented as well.

Figure 1. Panel A: Frontal chest radiography. Panel B: A comparison frontal chest radiograph performed one year earlier.

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph shows bilateral linear and reticular abnormalities
2. The chest radiograph appears normal and unchanged from previous
3. The chest radiograph shows multiple, bilateral poorly defined nodular opacities
4. The chest radiograph shows multifocal pleural abnormalities
5. The chest radiograph shows mediastinal widening

Reference as: Gotway MB. April 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;6(4):171-7. PDF

Medical Image of the Week: Septic Emboli

Figure 1. Photograph showing septic emboli to distal digits.

A 34 year old woman was admitted for a vasculitis workup after presenting with painful fingers, chest pain, and diffuse joint pain. Her blood cultures grew Staphyloccccus aureus and she was diagnosed with mitral and aortic valve endocarditis.  She had widespread joint involvement as well as a thoracic epidural abscess.

Jarrod Mosier, MD and Nathaniel Reyes, MD

Departments of Medicine and Emergency Medicine

University of Arizona

Tucson, Arizona

Reference as: Mosier J, Reyes N. Medical image of the week: septic emboli. Southwest J Pulm Crit Care. 2013;6(4):170. PDF