The increasing use of permanent mechanical contraceptive devices has placed growing demands on radiologists. Hysteroscopically placed tubal occlusion devices, in particular, must be evaluated promptly and carefully to verify that they are in a satisfactory location and are functioning effectively. Hysterosalpingography, radiography, ultrasonography, computed tomography, and magnetic resonance imaging all may be useful for this purpose; however, the acquisition and interpretation of images of these devices can be challenging and requires specific knowledge. Verification of tubal occlusion with a hysteroscopically placed device depends heavily on the adequacy of cornual distention with the contrast medium at hysterosalpingography. Some complications of coil (Essure device) placement, such as tubal perforation and device migration, may be clinically occult and their imaging appearances subtle; a high degree of suspicion is needed to detect them at postprocedural imaging. The position of another tubal occlusion device, a radiolucent silicone matrix (Adiana device), is not directly depicted at imaging with x-rays. By contrast, laparoscopically placed locking tubal clips are well depicted at radiography; however, their dislodgement and migration are seldom symptomatic and thus unlikely to be discovered in time to avert pregnancy. The use of any tubal occlusion device is associated with low albeit finite risks of unwanted intrauterine pregnancy, ectopic pregnancy, tubal and uterine perforation, and device migration into the peritoneal cavity. Results of multiple trials show that a substantial percentage of such complications occurred because of image misinterpretation and consequent patient reliance on tubal occlusion alone for contraception. Accurate description and classification of abnormalities in device position or function seen at imaging performed postprocedurally or for other clinical indications will enhance the value of radiologists' contributions to patient care.
Background Lemierre’s syndrome is a rare but potentially fatal condition. The course is characterized by acute tonsillopharyngitis, bacteremia, internal jugular vein thrombosis, and septic embolization. There have been some cases secondary to penetrating trauma to the neck. Literature review has yielded no cases secondary to blunt neck trauma in the absence of oropharyngeal injury. We aim to shed light on this unique cause of Lemierre’s syndrome, so as to raise the index of suspicion for clinicians working up patients with blunt cervical trauma. Methods We present a case of a 25-year-old male restrained driver who presented with left neck and shoulder pain with a superficial abrasion to the left neck from the seatbelt who was discharged same day by the Emergency Room physicians. He returned to the Emergency Department two days later with abdominal pain. As a part of his repeat evaluation, a set of blood cultures were sent and was sent home that day. The patient was called back to the hospital one day later as preliminary blood cultures were positive for Gram positive cocci and Gram negative anaerobes. Computerized tomography scan of the neck revealed extensive occlusive left internal jugular vein thrombosis and fluid collections concerning for abscesses, concerning for septic thrombophlebitis. The patient continued to decompensate, developing severe sepsis complicated by disseminated intravascular coagulation. Results The patient underwent a left neck exploration with en bloc resection of the left internal jugular vein, drainage of abscesses deep to the sternocleidomastoid, and washout/debridement of necrotic tissue. Direct laryngoscopy at the time of surgery revealed no injury to the aerodigestive tract. Wound cultures were consistent with blood cultures and grew Fusobacterium necrophorum, Staphylococcus epidermidis, and Methicillin-resistant staphylococcus aureus. The patient underwent two subsequent operative wound explorations without any evidence of residual infection. The patient was discharged home on postoperative day 13 on a course of antibiotics and aspirin. Conclusion This case illustrates the importance of diagnosis of Lemierre’s syndrome after an unconventional inciting event (blunt cervical trauma) and appropriate treatment.
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