3. Discussion
Our case presents a complicated patient with Lemierre Syndrome with septic shock secondary to Fusobacterium nucleatum with most sequelae involving osteomyelitis, multi-organ abscesses, pericardial effusion, and bilateral pleural effusions secondary to bilateral necrotizing pneumonia (left>right) with lung abscesses. Although the patient presented with presumed streptococcal pharyngitis due to exposure to college friends, it is imperative to swab and test patient before antibiotic administration. As the patient returned with continued fevers and worsening of symptoms, the suspicion for Lemierre’s syndrome is reasonable given patient’s age group and deteriorating respiratory status. However, it is not unreasonable to be suspicious for multisystem inflammatory syndrome in children (MIS-C) as well considering the era of SARS-CoV-2 23. Serologic inflammatory markers also make LS highly likely20. Of note, LS can also present as sinusitis or mastoiditis in young adults, and approximately 75% of patients are male. Those affected are young individuals who are usually immunocompetent without serious comorbidity1. The patient’s thromboembolic complications were not identified on any imaging studies; however, improvement with antibiotics, thoracentesis, VATS, and pleural fluid drained by chest tubes indicate that the etiology of medical condition to be suspicious for LS.
Due to Fusobacterium nucleatum’ s ubiquitous nature as normal flora in many healthy individuals’ oropharyngeal, gastrointestinal, and genitourinary tracts, it is imperative to obtain a history of the patient’s onset of symptoms. Our patient traveled to another state to visit friends, attended several social events, and shared utensils with multiple persons. Furthermore, the patient had dental work done approximately two months prior to onset of symptoms. With the initial onset of pharyngitis after her trip in the context of dental work and cleaning, patient may demonstrate weakened host mucosal barriers, allowing commensal organisms such as Fusobacterium nucleatum to disseminate into her bloodstream. Reported risk factors forFusobacterium bacteremia include immunosuppression, alcohol abuse, malignancy, older age, dialysis, and hospital acquired21. Moreover, Fusobacterium nucleatumhas been shown to be associated with liver involvement26, explaining patient’s scleral icterus bilaterally, which may have caused her vision to be temporarily bright and blurry in the ER18.
Our patient’s outside hospital admission included blood cultures, which successfully identified Fusobacterium nucleatum as the source of her infection. This pathogen may take up to 5-8 days to culture stressing the importance to administer empiric antibiotics with anaerobic coverage and varied diagnostic studies. Additionally, early detection of the pathogen is imperative to foster favorable prognosis. The rapid administration of treatment depends on the clinician’s awareness of LS and considering it as a differential diagnosis. It is not unreasonable to suspect LS in any young adult who presents with ongoing fevers in the recent episode of pharyngitis, even when source is unknown or presumed like streptococcus pyogenes .
Literature shows other patients with Lemierre’s syndrome have presented with severe sepsis and abdominal pain, treated with ampicillin-sulfabactum and metronidazole intravenously for three weeks, followed by a three-week course of oral amoxicillin/clavulanate, intravenous hydration, inotropic support, and thoracostomy tube drainage of pleural effusion12. Lack of characteristic neck symptoms or a negative initial neck ultrasound exam does not rule out LS.6 Case studies have demonstrated metastatic infections in the lung and brain including meningitis requiring aggressive management and therapies5, 19, 26. Another case study demonstrated patient with LS showing septic arthritis of right shoulder, as well as parapharyngeal abscess extending from base of skull to thoracic inlet, complicated by right IJV and subclavian vein thrombosis, and multiple lung emboli. Patient improved with oral clindamycin and metronidazole, IV gentamicin, IV piperacillin and tazobactam, incision and drainage of parapharyngeal abscess, and drain left in-situ13.
There are few case reports out of Belgium that reportFusobacterium as a possible complication of COVID-19 virus, as none of the patients had any risk factors for F. nucleatumbacteremia. All patients were adults with other comorbid factors21. They were tested COVID PCR positive for SARS-CoV-2, which resulted in digestive tract invasion and hence leading to Fusobacterium bacteremia21. Other organisms besides Fusobacterium necrophorum can cause LS such asStreptococcusProteusBacteroides , and Peptostreptococcus . In this particular case report, patient had severe respiratory and renal involvement without thrombosis of the jugular vein similar to our case22.
Lastly, it is imperative to not delay seeking medical attention due to concerns about the SARS-CoV-2 outbreak, as one patient with delayed care presented with atypical Lemierre’s syndrome involving the brain, liver, and lungs following a dental infection, ultimately resulting in serious and complex sequelae26.