Syndrome: A Real Pain in the Neck

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© Springer Nature Switzerland AG 2020
C. G. Kaide, C. E. San Miguel (eds.)Case Studies in Emergency Medicinehttps://doi.org/10.1007/978-3-030-22445-5_32



32. Lemierre’s Syndrome: A Real Pain in the Neck



Patrick Sylvester1   and Creagh Boulger1  


(1)
Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, Columbus, OH, USA

 



 

Patrick Sylvester (Corresponding author)

Email: Patrick.Sylvester@osumc.edu


 

Creagh Boulger

Email: Creagh.Boulger@osumc.edu


Keywords

Lemierre’s syndromeFusobacterium necrophorum Septic thrombophlebitis Internal jugular vein


Case


Sore Throat


Pertinent History


Patient presents to the emergency department with 1 month of sore throat. She had sought care twice already at the student health center of her local university and had been prescribed two rounds of oral antibiotics (amoxicillin and azithromycin, respectively). Both times, she says she had a rapid-strep test done, which was positive, and on the second encounter, she reports she had been tested for mono, which was negative. She had finished her last dose of azithromycin 5 days prior to arrival without significant improvement. In addition to the sore throat, she had persistent fevers up to 104 ° F, as well as palpable swelling of her right anterior neck, and pain with lateral rotation of her neck.


PMH


Reports frequent streptococcal pharyngitis, no chronic medical conditions, or daily medications.


SH


College student, never-smoker, occasional ETOH use.


Pertinent Physical Exam


Blood pressure 118/61, pulse 137, temperature 101.4 °F (38.6 °C), temperature source Oral, resp. rate 16, height 1.6 m (5′ 3″), SpO2 94%.


Except as noted below, the findings of the complete physical exam are within normal limits.



General:


No obvious distress. Appears to be handling secretions without issue.



HEENT:


Three finger trismus. She has erythema and fullness of right soft palate, uvula midline. There is a palpable 3 × 3 cm mass in right anterior neck at level of cricoid cartilage, tender to palpation with induration and central fluctuance. She reports pain and limited ROM on rightward lateral rotation of neck.



Respiratory:


Trachea midline. No respiratory distress. Breath sounds clear to auscultation bilaterally.


Pertinent Test Results






















































Lab results


Lab

Result

Units

Normal range

WBC

40.7

K/uL

3.8–11.0 103/mm3


Hgb

14

g/dL

(Male) 14–18 g/dL


(Female) 11–16 g/dL


Platelet

365

K/uL

140–450 K/uL


Creatinine

0.63

mg/dL

0.6–1.5 mg/dL


Lactate

2.6

mmol/L

< 2.0 mmol/L


ESR

31

mm/hr

0–22 mm/hr (male)


0–29 mm/hr (female)


CRP

187.7

mg/L

< 8 mg/L


ED Management


A soft-tissue CT scan of the neck with IV contrast was ordered to evaluate for peritonsillar abscess versus retropharyngeal abscess. Given the high suspicion for infection, empiric IV ampicillin/sulbactam and clindamycin were started.


Updates on ED Course



Update 1: (1210)


CT of the neck resulted showing a right peritonsilar abscess (1.4 cm × 2.1 cm × 2.0 cm) as well as complex cervical abscess of the right anterior neck (1.8 cm × 3.3 cm × 4.0 cm). The right internal jugular vein appears to be occluded throughout its cervical course.



  • Heparin was started with a bolus and an infusion.



  • Otolaryngology was consulted.


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Mar 15, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Syndrome: A Real Pain in the Neck

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