Monday, December 7, 2009

Acting in Vain

A previously healthy 20 year old man presents with sore throat, tooth pain, fever, and chills. His primary care doctor diagnoses him with pharyngitis, gives him some acetaminophen, and sends him home. Five days later, he is brought into the emergency department by ambulance with mental status changes and respiratory distress. His temperature is 40 degrees C, his blood pressure is 105/60, his pulse is 115, and his respiratory rate is 26. He is in acute distress with severe prostration, use of accessory muscles, and active rigors. His oropharynx shows an exudative tonsillitis. He has mild tenderness, swelling, and induration over the angle of his jaw and along the sternoclaidomastoid muscle. After he is stabilized, a CT scan of the chest shows multiple septic pulmonary emboli. A higher slice in the neck shows this:

The patient is started on broad spectrum antibiotics and admitted to the ICU. However, he still remains septic with positive blood cultures. He develops pulmonary infiltrates that evolve into abscesses and empyema. He then gets septic arthritis and osteomyelitis. Cultures grow out an oropharyngeal anaerobe Fusobacterium.

Challenge: What's your diagnosis?

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3 comments:

tree said...

Lemierre's!!!

Suheil said...

How about vincent's angina? Treatment is with antibiotic coverage for anaerobes in addition to surgical debridement...

Craig Chen said...

It's Lemierre's! Vincent's angina as well as Ludwig's angina are on the differential, but Vincent's is usually restricted to the gingiva and Ludwig's is bilateral without abscess formation.

By the way I think this is one of my better pun titles.
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Acting in Vain.

This is Lemierre's syndrome, also called jugular vein septic thrombophlebitis, postanginal sepsis, or necrobacillosis. In this syndrome, an infection extends from the oropharynx to the parapharyngeal or lateral pharyngeal space where it can involve the carotid sheath and cause persistent bacteremia, septic pulmonary emboli (97%) of cases, and metastatic abscesses.

Sources: UpToDate; ispub.com (The Internet Journal of Otorhinolaryngology).