British Journal of Radiology (2004) 77, 627-628
© 2004 British Institute of Radiology
doi: 10.1259/bjr/17786288
A patient with prolonged fever after pharyngotonsillitis
C Engelke, MD
E J Rummeny, MD
and
K Marten, MD
Department of Radiology, Klinikum der Technischen Universität München, Ismaningerstrasse 22, 81675 Munich, Germany
A 26-year-old medical student developed fever, neck pain and malaise 5 days after the diagnosis of cervical pharyngotonsillitis. He was treated on an outpatient basis with oral erythromycin but his symptoms did not improve and he developed cough with blood-tinged sputum. A chest radiograph showed pulmonary consolidation. The patient was treated with oral ciprofloxacine. However, he developed tender neck swelling and severe gluteal pain, and was admitted to a general district hospital where a chest radiograph revealed multiple pulmonary masses that were confirmed on chest CT (Figure 1
). Subsequently, an apparently inflammatory abnormality confirmed on neck CT was managed percutaneously. The patient was referred to our centre with a suspected diagnosis of active tuberculosis.
On admission the patient presented with fever, tachycardia, unilateral painful cervical swelling in the region of the treated neck abscess, dyspnoea at rest and left-sided gluteal pain. For these symptoms, CT of the neck and abdomen was performed (Figures 2 and 3). He had neutrophilia, elevated inflammatory markers and low serum antithrombin III levels. His blood gases were within normal limits.
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Figure 3. What does the neck CT show? What is the most likely unifying diagnosis? Does the patient require tuberculostatic therapy?
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The initial chest CT shows pulmonary masses, some of them with feeding vessels, displaying different stages of pulmonary cavitation due to pulmonary septic embolism with abscesses and more widespread peripheral consolidation (Figure 1
). Pelvic contrast-enhanced CT (Figure 2) reveals further communicating abscess formations within the left iliopsoas (Figure 2a) and gluteal muscle groups (Figure 2b), and cervical contrast-enhanced CT shows evidence of left internal jugular vein thrombosis consistent with septic thrombophlebitis (Figure 3). The gluteal abscess was managed percutaneously and the patient was treated with clindamycine and a high dose intravenous triple antibiotic combination including vancomycin, ceftacidine and metronidazole. Fusobacterium necrophorum was isolated from cervical and pelvic abscess aspirates. The pulmonary and pelvic abscesses resolved in the course of the patient's uneventful recovery and he was discharged after 46 days on oral medication of clindamycine and metronidazole for 8 weeks. 4 months later, he is well without recurrence of any symptoms and continues his training at medical school.
Postanginal necrobacillosis, referred to as Lemierre's septicaemia, is an uncommon, but potentially life-threatening complication of acute pharyngotonsillitis [1–3]. Originating from secondary anaerobic oropharyngeal infection with local invasion of the lateral pharyngeal space by F. necrophorum in 81% and by other Fusobacterium species in about 11%, it is characterized by septic thrombophlebitis of the ipsilateral internal jugular vein with subsequent metastatic abscess formation to the lungs and later, in approximately 15%, via systemic septic embolism to peripheral organs, including the musculoskeletal system, liver, spleen and meninges [4, 5]. With the decline of prevalence of Lemierre's syndrome in the antibiotic era the increasing lack of familiarity with this condition at presentation to ear, nose and throat surgeons, paediatricians and physicians can lead to serious delays in the diagnosis, followed by a fulminant course of the disease with potentially high mortality up to about 80% [1]. In the past decades reports pertaining to Lemierre's septicaemia in the radiology literature have been scarce. The purpose of this case report is to increase radiologists' awareness of this disorder, which often manifests as non-specific clinical and chest radiographic findings. It should be noted that signs of septic emboli may develop after admission and may be discovered only at follow-up chest CT. However, once there is evidence of internal jugular vein thrombosis or signs suggesting septic embolism to the lungs, the diagnosis will, in most cases, be straightforward, even with a comparatively "innocent-appearing" pharynx at the time of radiological workup [1–7]. This is of importance as the time required for microbiological confirmation from blood culture or aspirates may delay adequate high dose intravenous antibiotic treatment, which requires inclusion of an effective anaerobic agent. Because the radiological investigation is usually instrumental in reaching the diagnosis of Lemierre's septicaemia radiologists should be aware of this form of septic embolism, particularly in young and otherwise healthy patients without history of intravenous drug abuse.
Received for publication August 5, 2003.
Revision received March 5, 2004.
Accepted for publication April 27, 2004.
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References
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- Lemierre A. On certain septicaemias due to anaerobic aneurysms. Lancet 1936;1:701–3.[CrossRef]
- Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore) 2002;81:458–65.[CrossRef][Medline]
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