Yezan Abderrahman, MD
Pediatric Critical Care Fellow
University of Iowa Hospital and Clinics
Iowa City, IA, United States
Disclosure information not submitted.
Elizabeth Newell, MD
Assistant Professor, Pediatric Critical Care
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Shilpa Balikai, DO
Clinical Associate Professor, Pediatric Critical Care
University of Iowa Hospitals and Clinics, United States
Disclosure information not submitted.
Title: A Case of Severe Bilateral Lemierre’s Syndrome With Orbital Involvement
Case Report Body:
Introduction: Lemierre’s syndrome describes septic thrombophlebitis of the internal jugular veins caused by extension of anerobic infection from the oropharynx. Mortality and morbidity can be significant as multiple organs can be affected. In rare instances orbital involvement has been described
Description: An 11-year-old previously healthy male presented with 2 weeks of fever, sore throat, headaches, bilateral orbital pain, and periorbital swelling. He sought medical attention at the Emergency Department where pharyngeal streptococcus testing was negative and neck CT revealed small sized peritonsillar abscess with filling defects in internal jugular veins bilaterally. He was admitted and started on Unysn and Decadron. He remained febrile and his periorbital swelling and pain worsened. Repeat imaging revealed bilateral internal jugular veins narrowing, bilateral cavernous sinus thrombosis, complete thrombosis of left superior ophthalmic veins, and pansinusitis. Chest CT revealed multiple lung abscesses and bilateral pleural effusions. He underwent sinus washout with transient improvement in pain and swelling. Blood culture grew streptococcus anginosis, and sinus culture grew propionibacterium. Anticoagulation was initiated via heparin drip to achieve aPTT goal 40-60 seconds. Pain and fever worsened again, and repeat brain MRI revealed left retro-orbital abscess prompting transport to our unit. Blood work up revealed elevated white blood cell count 25.1 * 103 cell/mm3 with neutrophilic predominance, elevated erythrocyte sedimentation rate and C-Reactive protein at 83 mm/hr and 4.6 mg/dl, respectively. Physical exam was remarkable for bilateral proptosis and periorbital swelling while vision remained intact. Due to lack of improvement in patient’s clinical picture he was taken for functional endoscopic sinus surgery (FESS) with pus identified, and cleared, in right anterior ethmoids. Fever curve improved and inflammatory markers trended down with a 6-week course of broad-spectrum antibiotics. Additionally, he completed 14 weeks of anticoagulation with Enoxaparin and Apixaban.
Discussion: Our case highlights an extensive presentation of bilateral Lemierre’s syndrome complicated by bacteremia and endovascular thrombus formation in the orbit. Hypervigilance in diagnosis and prompt treatment are crucial.