Severe pneumonia and jaundice in a young man: an atypical presentation of an uncommon disease

Abstract

We present a patient with an atypical presentation of Fusobacterium infection, the genus responsible for Lemierre's syndrome. This syndrome, which often affects healthy, young people and can be fatal if not recognized and treated early, is defined as a history of recent oropharyngeal infection with clinical or radiological evidence of internal jugular vein thrombosis and isolation of anaerobic pathogens, mainly Fusobacterium necrophorum. The history, presentation, investigations and management of the patient are described and then contrasted with the existing literature surrounding Lemierre's syndrome, once termed the 'forgotten disease'. Case reportA previously fit and well 26-year-old male presented to hospital with a 3-day history of severe sore throat, general malaise, non-bloody diarrhoea, vomiting, fever and headache. He had no significant past medical history, did not take any medications and had no known allergies. He was an electric engineer who worked with air conditioning units and was an occasional drinker, a non-smoker and lived with his fiancé, their two children and a dog. He had no history of foreign travel and no risk factors for blood-borne viruses.On initial examination, the patient was clammy and febrile with jaundiced sclera. He had pharyngeal erythema and decreased air entry in the right lung base. Heart sounds were normal. He was tachycardic at 150 beats min 21 but normotensive. He was tender in the right upper quadrant and right lower quadrant with a 3 finger breadth palpable smooth liver edge. Neurological examination was normal.Initial blood tests revealed acute kidney injury with an estimated glomerular filtration rate of 32 ml min 21 , creatinine 207 mmol l 21 , urea 13.8 mmol l 21 and bicarbonate of 19 mmol l 21 . Leukocytes were raised with a neutrophilia and C-reactive protein was 258 mg l 21 . Haemoglobin was 14.9 g dl 21 , platelets 79610 9 l 21 and international normalized ratio 1.2. He had deranged liver function tests with a bilirubin level of 91 mmol l 21 , alanine aminotransferase 50 U l 21 , albumin 35 g l 21 and alkaline phosphatase of 128 U l 21 . Glucose was normal and blood cultures were sent. A chest radiograph showed patchy linear opacities in the right lower zone. An electrocardiogram showed sinus tachycardia.The initial diagnosis was community-acquired pneumonia. He was admitted under the medical team and treatment with intravenous fluids, co-amoxiclav and clarithromycin was initiated.The following day, the patient continued to be pyrexial, his oxygen requirements increased and he was referred to the Infectious Diseases team. On review, he had a PaO 2 of 10.14 kPa on 35 % FiO 2 with normal PCO 2 and pH, indicating type 1 respiratory failure with a wide arterial-alveolar gradient. Temperature was 40 u C and he remained tachycardic at 140 beats min 21 . He was noted to have pain in the right side of the neck with ipsilateral swelling on examination. Legionella and pneumococcal urinary antigen were negative. Renal function was improving but leukocytes and C-reactive pr...

Atypical presentation of Lemierre syndrome in a young healthy man with acute jaundice

“…The first case outlined a previously healthy male in his twenties who presented jaundice with sore throat, fever, diarrhoea and AKI. With this case, it was not until neck pain was noted that Lemierre syndrome considered and diagnostic investigations sent 14. This patient also improved with oxygen support, intravenous antibiotics, High Dependency Unit admission and intravenous fluids.…”

Severe thrombocytopenia and jaundice associated with Lemierre’s syndrome: A case report

“…It is uncommon for patients with Lemierre's syndrome to have jaundice, and only a few cases have been reported. [9] The incidence of jaundice associated with sepsis in the ICU is approximately 40%, and persistent jaundice has been regarded as a marker of patient morbidity and mortality. [10] In our case, the patient showed a significant increase in the direct bilirubin level.…”

Lemierre’s Syndrome: The Forgotten Disease?

“…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.…”