Sami Edris, MD
Resident Physician - Internal Medicine
Icahn School of Medicine at Mount Sinai (South Nassau), United States
Disclosure information not submitted.
Michael Megally, MD
Physician - Pulmonology/ Critical Care
Icahn School of Medicine at Mount Sinai (South Nassau), United States
Disclosure information not submitted.
Title: Septic Shock From Lemierre Syndrome in a Young Healthy Female With COVID-19 Coinfection
Introduction: Lemierre syndrome involves septic thrombophlebitis of the IJV. The condition typically begins with oropharyngeal infection with direct invasion into the pharyngeal space. Inflammation within the wall of the IJV can cause infectious thrombi to develop. The most common pathogen associated is the anaerobe F. necrophorum. We present the case of a healthy 23-year-old female with recent COVID-19 infection who was admitted to the ICU in septic shock of unknown etiology and ultimately diagnosed with Lemierre syndrome.
Description: A previously healthy 23-year-old female presented to the ED with fever, nausea, and vomiting for 1 week duration. The patient reportedly had a positive COVID-19 test result 1 week prior to presentation. After not responding to initial IVF boluses, she was subsequently placed on IV norepinephrine and admitted to the ICU for septic shock. IV cefepime, azithromycin, and metronidazole were started after gram stain showed gram negative bacilli. On hospital day 3, blood cultures returned positive for F. necrophorum. Given the known association of Fusobacterium species with septic thrombophlebitis, the patient was sent for CT neck which revealed a non-occlusive mid left IJV thrombosis. The patient was subsequently started on therapeutic enoxaparin. The patient improved clinically, lab markers normalized, and antibiotics were deescalated to oral metronidazole after culture sensitivities finalized. The patient was continued on rivaroxaban and advised to follow up with hematology after discharge to address the duration of therapeutic anticoagulation needed.
Discussion: Lemierre syndrome involves septic thrombophlebitis of the IJV. Prompt recognition is vital to prevent potential lethal complications such as lung abscess, empyema, and hematogenous spread to other sites. Strong anaerobic coverage with IV antibiotics should be administered for 2 weeks followed by oral antibiotics for a total of at least 4 weeks duration. There is an unclear benefit for anticoagulation in the setting of septic thrombophlebitis, but it should be considered when there is extension of IJV thrombosis or concern for embolization. There is currently no standard of care for anticoagulation in COVID-19 patients despite ongoing efforts to determine the efficacy and safety of several different anticoagulation strategies.