Alexis Keyworth, PA-C, MSHS
Physician Assistant, Cardiothoracic ICU
University of Colorado Anschutz Medical Campus
Aurora, CO
Disclosure information not submitted.
Caitlin Blaine, PA-C, MSHS
Physician Assistant
University of Colorado Anschutz Medical Campus
Aurora, CO
Disclosure information not submitted.
Hans Tregear, MD
Physician
University of Colorado, United States
Disclosure information not submitted.
Title: Lemierre's Syndrome and the Role of ECMO in Saving a Victim of Assault
Case Report Body:
Introduction: Lemierre’s syndrome is a rare but potentially deadly complication of pharyngitis which leads to septic thrombophlebitis of the internal jugular vein. Pulmonary complications are common and patients can develop cavitary pneumonia (PNA) due to septic pulmonary emboli. We present a case of Lemierre’s syndrome complicated by mycotic pulmonary artery aneurysm which progressed to severe acute respiratory distress syndrome (ARDS) requiring extracorporeal membrane oxygenation (ECMO).
Description: A 20-year-old female with recent physical assault and strangulation by her partner 9 days prior was admitted to an outside hospital with worsening dyspnea, neck pain and intermittent fevers since the day of the assault. She was subsequently intubated for hypoxemia. A CT of her neck and chest showed multifocal cavitary PNA with bilateral empyema and a thrombus in the right internal jugular vein as well as blood cultures positive for Fusobacterium necrophormun and Strepococcus intermedius. Despite appropriate management, she continued to require high ventilator support and on hospital day 10 developed large volume hemoptysis which led to cardiac arrest. Emergent bronchoscopy did not reveal active bleeding. After failing to show significant improvement with initiation of neuromuscular blockade and nitric oxide, she was transferred to our institution for initiation of veno-venous ECMO. We subsequently discontinued neuromuscular blockade and minimized sedation. With continued aggressive antibiotic therapy and a multi-disciplinary approach she was successfully decannulated after 19 days on ECMO.
A unique finding noted on chest CT on hospital days 19 and 30 demonstrated a pulmonary artery mycotic aneurysm involving the right lower lobe, which provided a potential etiology for her prior hemoptysis. Outpatient follow-up imaging 2 months after discharge demonstrated complete resolution of the mycotic aneurysm.
Discussion: Lemierre’s syndrome most commonly affects young healthy patients and can rapidly lead to death in its most severe form. In this unique case involving strangulation as a potential mechanism we present the utilization of ECMO as a means to support these patients through their ARDS while also avoiding the potential complications associated with high ventilator settings and prolonged use of neuromuscular blockade.