A Sore ThroatMorning Report 5/22/2014

Theadora Sakata, MDUniv of Utah Family Medicine

History of Present IllnessCC: Sore throat x 5 daysOtherwise healthy 16yo FAnxious momAlready seen @ PCH ED x1 (3 days ago), PCP’s office x3

What else would you like to know…?

HPI (all from Mom)5 days of sore throat and fevers to 104White spots on tonsilsDecreased PO intakeNon-bloody, non-bilious emesisNo diarrhea14-lb weight loss in the last 5 daysCough, paroxysmal and worse with sitting upRapid strep negative at PCP’s officeNo rashes

PMHx, PSHx, FHx, SHxPreviously healthy 16 year-old girlImmunizations up to dateNo prior hospitalizations or surgeriesNo one sick at homeNo regular meds, NKDA

Physical Exam:VITAL SIGNS: Heart Rate: 100 Resp: 24 Sats: 92% Temperature: 37.6CGEN: Awake, appears tired, pale, unwell. EYES: Conjunctivae and sclerae without injection. PERRLA, EOMI. ENT: TMs clear. + OP erythematous. No uvular deviation, trismus. Lips and mucous membranes dry. + purulent exudates on tonsils.NECK: Supple, full ROM. Neg Kernig, Brudzinski.RESP: CTAB. No adventitious breath sounds. CV: Tachycardic. No gallop or murmur. Cap refill 4-5 seconds.GI: Soft, subj TTP in RUQ. No rebound, guardin, organomegalyMSK: Warm. No edema.SKIN: No rashes or skin lesions. No petechiae observed.NEURO: Strength and tone appropriate for age.

Differential?

What diagnostics would you like to order?

Labs:WBC 17.7 (62% bands, ANC 16.3), Hgb 13.4, Hct 38.1, Plt 15Na 135, K 3.2, Cl 98, CO2 15, BUN 82, Cr 3.01, Glu 94

CRP 32.6PT 14.7, INR 1.2, PTT 26

Infectious mononucleosis screen: NEGCSF studies: Total protein 21, Glucose 82, WBC 4, RBC 3

CSF cultures sent.Urine culture sent. Blood cultures sent.

Imaging – Portable CXR

Imaging – Neck US

Blood culture result

Fusobacterium necrophorum.

Lemierre SyndromeAka jugular vein suppurative

thrombophlebitis, postanginal sepsis, necrobacillosis

Pharyngitis, internal jugular thrombophlebitis, septic pulmonary emboli, persistent fever.

Pharyngitis to thrombophlebitis within 1 week.

Fusobacterium necrophorum (aka Bacillus funduliformis, arch.)

Some affiliation with infectious mononucleosis.

Median age 19, with 89% of cases between 10-35 years.

Incidence 0.8-1.5 per million per year (European data)

Lemierre SyndromeOrganism first described in

1898 by Jean Halle in his thesis on human female genital tract microbiology

Syndrome first described in humans in 1900 by Courmant and Cade

Lemierre tied the clinical findings to the organism in 1936, earning the name.

Physician and professor of microbiology and ID at the Hospital Claude Bernard, Paris.

Andre Lemierre(1875-1956)

Carotid Sheath & the Parapharyngeal Space

Septic emboli & lytic lesions

Treatment:ANTIBIOTICS - Beta-lactamase resistant beta-lactam until susceptibilities result.

Vancomycin and meropenem until speciation and susceptibilities returned, then Penicillin G 23 million units continuous infusion for 6 weeks from 1st negative culture.

SURGERY – Consider surgical ligation or IJ excision; consider surgical drainage of empyemas or pulmonary abscesses. No RCTs. No surgical intervention needed for this patient. ANTICOAGULATION – Controversial, no RCTs.

Anticoagulated with Lovenox for 12 weeks because of fully occlusive IJ clot and concern for an underlying coagulopathy with workup completed outpatient.

Sources, references…Brook I. “Anaerobic bacteria in upper respiratory tract and head and neck infections: microbiology and treatment.” Anaerobe. 2012 Apr; 20(2): 214-20. doi: 10.1016/j.anaerobe.2011.12.014. Epub 2011 Dec 20.

Fua et al. “Lemierre Syndrome – Should We Anticoagulate? A case report and review of the literature.” International Journal of Angiology. 2013 Jun; 22(2): 137-42. doi: 10.1055/s-0033-1336828

Riordan T. “Human Infection with Fusobacterium necrophorum (Necrobacillosis),with a Focus on Lemierre’s Syndrome.” Clinical Microbiology Reviews. 20 (4): 622-659 . October 2007.

Spelman, Denis. “Suppurative (septic) Thrombophlebitis.” Up To Date. Accessed 5/19/2014. Last updated 8/14/2013.

Questions, Comments, Discussion…

Presented to her PCP three times…?