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.