T Anoop, M Biju, J Pappachan, R Manjula, S Abraham, K Jayakumar
acute renal failure, fusobacterium necrophorum, lemierre's syndrome
T Anoop, M Biju, J Pappachan, R Manjula, S Abraham, K Jayakumar. Lemierre's Syndrome: An Unusual Presentation. The Internet Journal of Otorhinolaryngology. 2006 Volume 6 Number 1.
A 46 year old man with diabetes was admitted for evaluation of high grade fever and oligura following a sore throat. On admission he had acute renal failure. He also had a painful neck swelling the radiograph of which showed the presence of gas inside it. CT scan of the neck showed a gas filled abscess. Doppler study of the neck revealed thrombosis of the left internal jugular vein. Blood culture and culture of the aspirate from the abscess had grown
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A 46-year old man was admitted for evaluation of high-grade fever for one week and vomiting and oliguria for 2days. He had sore throat for a few days 2 weeks prior to the admission and had noticed a painful swelling on the left side of the neck 4 days before admission. He also had type 2 diabetes mellitus for the past one year that had been well controlled with glipizide 5mg daily.
On admission his temperature was 40.5°C, pulse rate 120 beats/min, respiratory rate 33/min and blood pressure 94/70mm of Hg. He was clinically dehydrated. Throat examination revealed mild congestion of the tonsils. A tender swelling was palpable in the left supraclavicular region. Rest of the systemic examination was unremarkable.
The initial laboratory investigations were: haemoglobin concentration 100 g/L, white cell count 14.6 x 109/L, neutrophils 12.4 x 109/L, lymphocytes 2.2 x 109/L, platelet count 190 x 109/L, erythrocyte sedimentation rate 110 mm in the first hour, plasma glucose 17 mmol/L, urea 94 mmol/L, creatinine 406 micromol/L and bilirubin level 61 micromol/L. Other liver tests, sodium, potassium, corrected calcium and inorganic phosphates were within the reference range. Urine microscopic examination and the ketostix reaction were unremarkable. Fractional excretion of sodium was 1.2%. Chest radiograph was normal and the serological assays for leptospirosis, dengue virus and hepatotrophic viruses were negative. The electrocardiograph showed only sinus tachycardia. Peripheral blood smear revealed normocytic normochromic anaemia and neutrophilia with toxic granulations.
Ultrasonography of neck swelling showed a focal heterogenous area of 3.5cm diameter with ill-defined borders in the intramuscular plane. Doppler study of the neck revealed absence of blood flow in the left internal jugular vein and a thrombus inside the vein (Fig 1B).
Lateral view radiograph of the neck showed a gas shadow in the neck (fig 2A: arrow) and CT scan images of the neck (contrast study was not done because of the renal failure) confirmed the gas filled abscess in the left supraclavicular region (Fig 2B: arrow).
A diagnosis of Lemierre's syndrome was made and the patient was managed by surgical drainage of about 40ml of foul smelling pus from the abscess with a 4 cm long vertical incision in the posterior triangle on the left side of neck. Subcutaneous insulin, intravenous clindamycin 600mg 12th hourly and metronidazole 500mg 8th hourly also were administered. He required 4 alternate day sessions of hemodialysis for renal failure. On the 4th day of the treatment the blood culture and culture of the pus from the neck swelling showed the growth of
Lemierre's syndrome, also called necrobacillosis/post anginal sepsis, is characterized by acute pharyngeal infection most often with
Complications described in Lemierre's syndrome include pulmonary lesions (embolism, suppurative pneumonia, abscesses and empyema), clinical jaundice, internal jugular vein thrombosis, septic arthritis, septic shock, skin and soft tissue lesions, renal failure, meningitis, osteomyelitis and clinical DIC in the descending order of frequency3.
Intravenous antibiotics directed against anaerobes and drainage of abscesses in accessible sites are the ideal treatments recommended.
For an infection associated with such severe sepsis, acute renal failure requiring dialysis is remarkably uncommon in patients with Lemierre's syndrome1,3. Acute tubular necrosis (secondary to hypovolemia and systemic sepsis) was the probable cause for renal failure in this case and the high fractional excretion of sodium and rapid and complete recovery following treatment also suggest the same.
Several features of this case such as higher age at presentation, absence of overt pulmonary complications and development of acute renal failure necessitating hemodialysis were unique.
Dr. M J Pappachan, Senior lecturer in medicine, Kottayam Medical College, Kottayam, Kerala, South India-686008. Tel: +91 94474 32633. E-mail: firstname.lastname@example.org