Lemierre's syndrome secondary to community-acquired methicillin-resistant Staphylococcus aureus infection presenting with cardiac tamponade, a rare disease with a life-threatening presentation: a case report

Abstract

BackgroundLemierre's syndrome is a rare condition characterized by thrombophlebitis of internal jugular vein, septicemia and septic metastatic infection of different organs. It is preceded by an oropharyngeal infection by anaerobic organisms. Community-acquired methicillin-resistant Staphylococcus aureus is now emerging as a causative organism in Lemierre's syndrome. Clinical manifestations vary depending on the organ system affected by the infection. Although rare, patients may present with life-threatening conditions such as cardiac tamponade.Case presentationWe report the first case, to our knowledge, of Lemierre's syndrome presenting with cardiac tamponade secondary to community-acquired methicillin-resistant S. aureus in a previously well 45-year-old Sri Lankan lady. Fever, sore throat and left-sided neck pain complicated with facial and left upper limb swelling were followed by severe shortness of breath for 24 h. There was tachycardia with pulsus paradoxus, low blood pressure and soft heart sounds. Pericardial effusion with cardiac tamponade was detected on echocardiogram and methicillin-resistant S. aureus species were isolated in both blood and pericardial fluid cultures. Venous duplex of neck veins and computed tomography scan of the neck showed thrombosis of left-sided internal jugular, external jugular, subclavian and axillary veins. Diagnosis of Lemierre's syndrome was made, and patient had a satisfactory recovery following emergency pericardiocentesis and a prolonged course of antibiotics.ConclusionsAlthough uncommon, Lemierre's syndrome is a life-threatening condition. Patients may present with cardiac tamponade secondary to purulent pericarditis in Lemierre's syndrome, where emergency pericardiocentesis is lifesaving. Community-acquired methicillin-resistant S. aureus is emerging as a causative agent in Lemierre's syndrome, and awareness is required amongst physicians for prompt diagnosis and appropriate empirical treatment to prevent mortality and morbidity associated with the disease.

Lemierre’s Syndrome: The Forgotten Disease?

“…Although F. Necrophorum is the most common organism reported to cause Lemierre's syndrome, up to one third of patients have a polymicrobial bacteraemia [5]. Frequently present are other miscellaneous anaerobic streptococci and gram negative anaerobes including Bacteroides, Eikenella corrodens, Proteus mirabiliss, Petostreptococcus, Streptococcus oralis, Lactobacilli, Candida and meticillin resistant and sensitive Staphylococcus aureus [11][12][13].Gemella morbillorum isolated in this case study is also a recognised pathogen causing Lemierre's syndrome, albeit it rare.…”

“…Clinical findings during the primary stage are dependent on the initial site of infection. In most reviews and studies sore throat and evidence of pharyngeal inflammation are the primary findings [5,11,13,15,26,41,42]. Fever presents in 82.5% of patients [1], but may not be present at the time of initial presentation.…”

“…In the pre-antibiotic era this syndrome was far more common and was often fulminant and fatal in 7-15days, with a 90% mortality rate [1,2,5]. However with the advent of antibiotics in the late 1940's there was a rapid decline in the number of reported cases of Lemierre's syndrome and it soon became the "forgotten disease".…”

Community acquired methicillin resistant Staphylococcus aureus soft tissue infection complicated by septicaemia, necrotizing pneumonia, deep vein thrombosis and pyomyositis

“…Ansorp study which had been conducted in the adult population in eight Asian countries, including Sri Lanka, has reported the high prevalence of hospital and community acquired MRSA strains 2 . A case report of infant with CA-MRSA infection with abscess formation and septicaemia 8 and a few other case reports in adults 9 with invasive disease have been reported in Sri Lanka. Many of the CA-MRSA strains have acquired the Panton Valentine Leukocidin (PVL) gene that produces a series of chemicals contributing to the invasiveness.…”

Thrombophlebitis of the internal jugular vein after tonsillectomy

“…Clinical manifestations vary depending on the organs affected by infection [9]. Fever and gastrointestinal discomforts are found in 82% of all cases [1].…”