Case
Patient: A 36-year-old woman.
Chief complaints: Fever, posterior cervical pain, facial
swelling, right visual acuity loss
Medical history: No major diseases, including immune disorders.
Family history: Nothing in particular.
Lifestyle history: Nonsmoker and occasional drinker. The patient
was not on any oral medications.
History of present illness: The patient developed a fever 1 week
before the hospital visit. Two days later, she developed difficulty in
swallowing and trismus and sore throat. By the following day, she had
facial swelling and posterior cervical pain. She kept monitoring her
condition at home. However, the symptoms did not improve, and she began
having difficulty in moving, which prompted an ambulance request 1 week
later and the patient’s being transported to our hospital.
Physical findings at the hospital visit: Height, 155 cm; body
weight, 55 kg; clear consciousness; body temperature, 38.0°C; heart
rate, 110 bpm (regular); blood pressure, 98/76 mmHg;
SpO2, 95% (room air); respiratory rate, 27 breaths per
minute; no chills and shivering; no night sweats; right-dominant facial
swelling; examination of the oral cavity and pharynx proved difficult
due to trismus; swelling and tenderness noted in the right cervical
area; no stiff neck; no chest pain; clear pulmonary sounds; no clear
abnormalities in the cardiac sound; flat and soft abdomen; no
spontaneous pain and tenderness; and no limb swelling.
Abnormal neurological findings (cranial nerves): II, right visual
acuity loss; III/IV/VI, right eye midline immobilization, no oculomotor
disorder in the left eye; V, no left/right differences in facial
sensation; VII, trismus/difficulty in opening the right eye; VIII, no
left/right differences in hearing; IX/X, difficulty in swallowing; XI,
no weakness or left/right differences in the sternocleidomastoid and
trapezius muscles; XII, the tongue could not extend beyond dentition
because of trismus.
Laboratory findings at the hospital visit: Arterial blood gas
analysis (room air) showed pH, 7.409; PaCO2, 38.9 Torr;
PaO2, 80.2Torr; and bicarbonate, 24.1 mmol/L. She had no
respiratory failure. Blood work revealed a white blood cell count of
21,900/µL, platelet count of 1.8× 104 μL, C-reactive
protein level of 26.73 mg/dL, quantitative fibrinogen level of 680
mg/dL, Fibrin degradation product level of 4.8 µg/dL, and D-dimer level
of 1.8 µg/dL, which indicated an elevated inflammatory response,
thrombocytopenia, and high D-dimer level. The acute stage score of
disseminated intravascular coagulation (DIC) was 4 points. Therefore,
she was diagnosed with DIC.
Images at the hospital visit: The contrast-enhanced computed
tomography (CT) showing a low-density area in the C2-6 prevertebral
muscles, and a poorly enhanced area in the right internal jugular vein.
(Fig.1.2) There are also Multiple ground-glass nodules are in both
lungs, predominantly on the pleural side.(Fig. 3)
The patient was diagnosed with Lemierre’s syndrome, based on the images
indicating retropharyngeal abscess, thrombophlebitis, and septic
pulmonary embolism.
After admission, the patient was managed in the intensive care unit.
At the time of admission, trismus was observed, and CT showed airway
stenosis. Securing the airway was necessary. Therefore, the patient
underwent emergency tracheotomy in the primary care room, after
undergoing a platelet transfusion.
Local drainage of the retropharyngeal abscess was attempted, but it was
impossible to visualize and treat the locality of the pharynx because of
trismus; therefore, conservative treatment with antibiotics was
administered. Meropenem 1 g IV every 8 hours and vancomycin 1 g IV every
12 hours were the empiric antimicrobial agents. Anticoagulant therapy
was not started on admission because the patient was in a state of DIC
at the time of admission. The patient was diagnosed with orbital-apex
syndrome due to the spread of inflammation from the retropharyngeal
abscess.
Treatments with antimicrobial agents gradually improved the inflammatory
parameters, facial swelling, and posterior cervical pain. Blood culture
sampled upon admission revealed Fusobacterium necrophorum .
Therefore, the antimicrobial treatments were de-escalated to
ampicillin/sulbactam 3 g IV every 6 hours on Day 6 after admission,
based on the susceptibility results. Anticoagulant therapy was also
started with systemic administration of heparin. Heparin was switched to
a direct-acting oral anticoagulant on Day 11, as the patient had no
exacerbation in her general condition.
On Day 35, antimicrobial treatments were de-escalated to amoxicillin 500
mg orally 3 times daily. Antimicrobial treatments were terminated on Day
42, after confirming that the abscess had disappeared completely on the
follow-up CT scan.
However, even after the abscess disappeared, the patient’s reduced
visual acuity and oculomotor disorder did not improve. The patient was
discharged with these symptoms remaining.